nOLOG''  •JBRAIf 


LOCAL  ANESTHESIA 


SCTENTIFTC  BASIS  AND  PRACTICAL  IISI^] 


PROF.   DR.   HEINRICH   BRAUN 

Obermedizinalr.\t  and  Director  of  the  Kgl.  Hospital  at  Zwickau,  Germany 
TRANSLATED  AND  EDITED  BY 

PEECY  SHIELDS,  M.D.,  A.C.S. 

Cincinnati,  Ohio 

FROM  THE  THIRD  REVISED  GERMAN  EDITION 

WITH    215    ILLUSTRATIONS    IN    BLACK    AND    COLORS 


LEA  &  FE.BIGER 

PHILADELPHIA   AND    NEW   YORK 
1914 


Entered  according  to  the  Act  of  Congress,  in  the  year  1914,  by 

LEA  &   FEBIGER, 
in  the  Office  of  the  Librarian  of  Congress.     All  rights  reserved. 


ritKrAoi-;  to  tiii-;  FiitsT  knijlish  from  tiik  tiimu) 

GERMAN  EDITION. 


The  writer  of  this  work,  Professor  Braiin,  has  justly  been  called  "the  father  of 
local  anesthesia."  INIy  object  in  placing  his  work  at  the  command  of  the  English- 
speaking  surgical  profession  is  to  systematize  the  vague,  erratic,  and  unsatisfactory 
efforts  which  have  been  made  in  this  field  for  many  years,  by  offering  a  logical 
procedure  based  upon  scientific  facts  and  having  an  exact  and  undeviating  technique. 

Considering  the  brilliant  results  that  are  being  obtained  especially  in  Germany 
with  infiltration  and  conduction  anesthesia,  it  is  with  much  pride  that  we  can  number 
among  our  American  confreres,  men  who  were  pioneers  in  this  particular  form  of 
anesthesia.  IVIatas,  Gushing,  Gorning,  Grile  and  others  attempted  conduction  anes- 
thesia shortly  after  the  introduction  of  cocaine  in  1884.  Their  methods,  however, 
held  but  a  minor  place  in  surgery  until  the  introduction  of  the  suprarenal  prepara- 
tions and  the  less  toxic  substitutes  for  cocain.  It  was  only  after  the  discovery  of 
the  active  salts  of  the  suprarenal  gland  by  Takamine  in  1901  that  the  progress  of 
local  anesthesia  became  assured,  for  without  its  use  anesthesia  sufficient  for  surgical 
purposes  was  impossible. 

In  this  translation  I  have  attempted  to  adhere  as  closely  to  the  text  as  the  differ- 
ences in  the  two  languages  would  permit,  for  which  reason  I  hope  I  may  be  pardoned 
for  the  occasional  repetitions  which  Prof.  Braun  uses  in  his  work  to  impress  certain 
important  facts.  Because  of  the  merit  of  this  German  text-book  it  is  a  pleasure  to 
stand  sponsor  for  the  English  translation.  I  am  indebted  to  Prof.  Braun  for  accord- 
ing me  the  privilege  of  translating  his  work,  which  represents  years  of  patient  toil 
in  the  perfection  of  technique,  as  it  exists  today. 

The  profession  must  and  will  accept  a  method  of  anesthesia  which  has  no 
mortality,  and  will  use  it  in  many  cases  which  are  today  being  operated  upon  under 
general  anesthesia.    Without  casting  any  reflection  upon  the  men  who  have  devoted 


399486 


iv  PREFACE 

their  time  and  energy  to  the  development  and  improvement  of  the  technique  of 
general  anesthesia,  it  cannot  be  gainsaid  that  the  latter  will  always  carry  with  it  a 
definite  mortality.  Leaving  the  many  other  advantages  of  local  anesthesia  out  of 
consideration,  the  absence  of  mortality  and  injury  to  the  tissues  should  give  it  a 
permanent  place  in  surgery. 

I  am  indebted  to  Dr.  Bertha  Lietze  for  her  efficient  help  in  this  translation. 

P.  S. 
Cincinnati,  Ohio,   1914. 


AUTHORS  PREFACE  TO  THE  THIUD  EDITION. 


The  extensive  use  of  local  anesthesia  in  general  surgery  has  heretofore  been  possible 
only  to  those  who  ha\e  made  a  study  of  the  literature  and  who  have  learned  by  prac- 
tice and  experience  the  methods  and  their  limitations.  The  various  surgical  text- 
books give  but  a  very  superficial  knowledge  of  local  anesthesia,  whereas  the  special 
monographs,  as  a  rule,  overestimate  the  value  of  one  particular  method.  Many 
monographs  have  appeared  in  recent  years  which  have  simplified  the  technique. 
They  have  shown  that  the  indiscriminate  use  of  any  particular  method  is  not  permis- 
sible, that  nearly  every  operation,  every  tissue,  in  fact  every  part  of  the  body,  requires 
a  particular  technique  for  anesthesia,  and  that  operations  can  only  be  carried  out 
under  this  method  after  a  most  careful  study  of  the  innervation  of  the  operative 
field. 

It  seems,  therefore,  timely  that  we  should  collect  what  knowledge  we  have  at  present 
of  local  anesthesia.  As  is  well  known,  I  have  for  years  worked  toward  this  end.  On 
the  one  hand  I  have  enlarged  upon  my  numerous  contributions  in  reference  to 
the  results  of  my  experience  with  the  scientific  basis  of  local  anesthesia,  and  on  the 
other  hand  I  have  eliminated  the  unimportant  facts  from  the  contents  of  this  book. 
I  have  attempted  to  demonstrate  objectively  the  development  of  the  various  local 
anesthetic  methods  so  that  the  student  will  be  able  to  make  practical  use  of  local 
anesthesia  without  the  necessity  of  investigating  a  very  extensive  literature.  This 
has  been  accomplished  by  a  description  of  many  operations  performed  under  local 
anesthesia,  with  the  aid  of  numerous  illustrations,  a  number  of  which  are  photo- 
graphs taken  during  these  operations  for  the  purpose  of  demonstrating  the  possibilities 
of  local  anesthesia  and  the  value  of  a  better  understanding  of  the  technique.  This 
portion  of  the  book  is  naturally  of  a  subjective  character,  as  it  has  only  been 
possible  for  me  to  describe  operations  under  local  anesthesia  after  obtaining  a 
knowledge  of  all  methods  and  experiments  carried    out  over  a  period  of  years. 


The  technique,  as  is  well  known,  has  been  markedly  influenced  by  the  introduction 
of  suprarenin.  The  photographs  and  sketches  have  been  made  by  me  in  large  part. 
For  a  clear  understanding  of  local  anesthesia,  a  knowledge  of  its  use  in  the  special 
branches,  such  as  ophthalmology,  otology,  rhinology,  gynecology,  and  urology,  is 
necessary.  These  departments  have  made  such  progress  that  we,  as  surgeons,  cannot 
overlook  them.  My  experience  in  the  fields  of  surgery  and  the  specialties  has  been 
rather  extensive.  Thus  I  may  be  able  to  suggest  some  things  even  to  the  specialist. 
Nevertheless,  in  writing  this  portion  of  the  book  I  have  been  aided  by  specialists 
in  their  respective  fields,  but  I  am  particularly  indebted  in  this  direction  to  Prof. 
Dr.  Schwarz  and  Dr.  Viereck  for  their  help.  I  also  considered  a  description  of 
medullary  anesthesia  as  necessary,  inasmuch  as  it  forms  a  part  of  local  anesthesia, 
and  within  certain  limits  is  of  much  practical  value. 

Prof.  Dr.  H.  Braun. 


CONTENTS. 


CHAPTER   1. 

History  of  Local  Anesthesia  up  to  the  Discovery  of  Cocain 17 

CHAPTER   II. 

Sensation  and  Pain.     Anesthesia  and  Anesthetic  Methods 27 

CHAPTER   III. 

The  Pain-relieving  Action  of  Nerve  Compression  and  Anemia 41 

CHAPTER   IV. 

Anesthesia  by  Means  of  Cold 45 

CHAPTER   V. 

The  Osmotic  Tension  OF  Watery  Solutions.     Tumefaction  and  Dehydration  Anesthesia  55 

CHAPTER   VL 

Indifferent  and  Active  Substances.     Absorption  and  Local  Poisoning.     Methods  of 
Testing.     General  Properties  and  the  Methods  in  the  Use  of  Local  Anesthetic 

Agents G4 

CHAPTER   VII. 

Local  Anesthetic  Drugs 74 

1.  Cocain 74 

History  of  Cocain  Anesthesia  and  Poisoning 75 

The  Nature  and  Mechanism  of  Local  Cocain  Poisoning          79 

The  Nature  and  Mechanism  of  General  Cocain  Poisoning S5 

Prevention  and  Treatment  of  Cocain  Poisoning,  the  Dosage  of  Cocain,  Local  Injury 

to  the  Tissues  from  Cocain 91 

Methods  of  Preparation  and  Sterilization  of  Cocain  Solutions 9G 

The  Use  of  other  Cocain  Combinations 97 

2.  Tropacocain 100 

3.  Eucain 103 

4.  Holocain 108 

5.  Aneson 109 

6.  Akoin 109 

7.  Anesthetics  of  the  Orthoform  Group 113 

8.  Stovain US 

9.  Alypin 119 

10.  Novocain 121 

11.  Other  Anesthetics 126 


viii  CONTENTS 

CHAPTER  VIII. 
Aids  to  Local  Anesthesia.    The  Effects  of  the  Vitality  of  the  Tissues  and  the  Local 

AND  Toxic  Action  of  Local  Anesthetic  Substances.     Suprarenin 129 

CHAPTER  IX. 

The  Various  Methods  for  Using  Local  Anesthetic  Substances 146 

1.  Anesthesia  of  the  Superficial  Surfaces  such  as  Mucous  Membrane,  Serous  Membranes, 

Synovial  Membranes  and  Wounds 146 

2.  Electric  Cataphoresis  as  an  Aid  to  Local  Anesthesia 148 

3.  Infiltration  Anesthesia 149 

4.  Conduction  Anesthesia 156 

(a)  Perineural  Injections 157 

(5)   Endoneural  Injections 161 

(c)   Lumbar  and  Sacral  Anesthesia 163 

5.  Vein  Anesthesia 163 

6.  Arterial  Anesthesia 166 

CHAPTER  X. 

Value,  Indications  and  General  Technique  for  Local  Ane.sthesia 168 

Instrumentarium 171 

Anesthetic  Solutions 177 

General  Technique  of  Infiltration  and  Conduction  Anesthesia 180 

CHAPTER   XI. 

Operations  upon  the  Head 194 

1.  Operations  upon  the  Scalp  and  Forehead.     Operations  on  the  Skull 194 

2.  Operations  on  the  Ear 204 

3.  Blocking  of  the  Trigeminus  Trunk 210 

4.  Operations  in  the  Orbit.     Eye  Operations 230 

5.  Operations  upon  the  Soft  Parts  of  the  Face 235 

6.  Operations  in  the  Nasal  Cavities  and  the  Bones  of  the  Nose 240 

7.  Operations  on  the  Frontal  Sinuses 244 

8.  Operations  upon  the  Jaws 246 

9.  Extraction  of  Teeth  and  other  Operations  upon  the  Alveolar  Processes  of  the  Upper 

and  Lower  Jaw 253 

10.  Operations  on  the  Palate.    Nasopharyngeal  Fibromata 261 

11.  Operations  upon  the  Tongue,  Floor  of  the  Mouth  and  Tonsils 262 

CHAPTER   XII. 

Operations  on  the  Neck 267 

CHAPTER  XIII. 

Operations  upon  the  Spinal  Column  and  Bony  Thorax 278 

CHAPTER  XIV. 

Abdominal  Oper.ations 296 

CHAPTER  XV. 

Genito-urinary  and  Rectal  Operations 315 

CHAPTER  XVI. 

Operations  on  the  Extremities 344 


LOCAL  ANESTHESIA. 


CHAPTER   I. 


HISTORY  OF  LOCAL  ANESTHESIA  UP  TO  THE   DISCOVERY  OE 
COCAIN. 

The  most  important  step  in  the  development  of  modern  surgery,  following  the 
antiseptic  or  rather  aseptic  treatment  of  wounds,  has  been  the  possibility  of  operating 
without  pain.  The  danger  and  pain,  together  with  most  uncertain  final  results  follow- 
ing the  slightest  surgical  procedure,  were  the  heavy  responsibilities  imposed  upon 
the  science  of  surgery  in  early  days.  The  attempt  to  improve  upon  the  treatment 
of  wounds  was  like  groping  in  the  dark,  as  long  as  the  cause  of  wound  infection  and 
the  methods  of  overcoming  it  were  unknown.  The  ways  of  relieving  the  patient  from 
surgical  pain  were  far  more  clearly  defined.  The  desire  to  relieve  pain  is  as  old  as 
the  history  of  man,  but  its  consummation  extended  over  many  centuries,  during 
which  endless  efforts  were  made  to  relieve  the  suffering  of  mankind,  as  was  so 
forcibly  expressed  in  the  words  of  Hippocrates:  "Divinum  est  opus  sedare  dolorem." 
Attempts  to  reach  this  goal  continued  for  almost  two  thousand  years  after  Hippocrates, 
as  may  l)e  judged  from  the  countless  errors  made  in  the  effort  to  relieve  pain, 
which  just  before  the  discovery  of  anesthesia  caused  Velpeau  to  give  expression  to 
his  thoughts  in  the  disconsolate  words,  "Eviter  la  douleur  dans  les  operations,  est 
une  chimere,  qui  n'est  pas  permise  de  poursviivre." 

We  learn  from  tradition  of  the  attempts  of  the  Egyptians,  Chinese,  Greek, 
and  Roman  physicians,  also  medicine  men  of  Africa  (Felkin),  to  induce  sleep 
artificially.  They  knew  of  the  stupefying  effects  of  the  narcotic  juices  of  plants 
and  used  them  in  the  form  of  drinks  to  relieve  the  pain  of  patients  undergoing 
surgical  operations.     Alcohol  was  also  used  for  many  years  for  this  purpose. 

I  )uring  the  Middle  Ages  narcotic  inhalations  were  used  in  the  effort  to  produce 
general  anesthesia.  Sponges  soaked  in  the  juices  of  the  miracle-producing  man- 
drake root,  hemlock,  henbane,  and  poppy,  so-called  sleep  sponges,  were  used  to 
convey  the  essence  of  various  plant  juices  to  the  patient  to  induce  sleep.  These 
were  the  only  means  at  the  disposal  of  the  surgeons  in  this  early  period.  The  older 
2 


18  LOCAL  ANESTHESIA 

methods  of  narcosis  were  too  dangerous  when  effective,  and  were  ineffective  when 
free  from  danger.  There  is  no  doubt  that  hfe  is  endangered  if  a  patient  is  so 
benumbed  with  alcohol,  opium,  cannabis  indica,  etc.,  that  the  sense  of  pain  during 
operation  is  lost.  On  the  other  hand,  we  know  that  a  semiconscious  patient  does 
not  withstand  operation  so  well  as  one  fully  conscious,  and  resists  the  efforts 
of  the  surgeon  more  than  the  latter.  For  this  reason  narcosis  by  this  method 
was  rarely  used,  and  toward  the  end  of  the  Middle  Ages  was  entirely  gi\'en  up  by 
the  surgeons. 

By  means  of  various  precautionary  methods,  some  fantastic,  some  useful,  attempts 
were  made  to  lessen  the  pain  and  shorten  the  duration  of  the  operation  which  must 
now  be  looked  upon  as  a  step  in  the  advancement  of  knowledge.  We  learn  that 
greased  and  warm  instruments  should  lessen  pain  in  cutting  through  tissues,  in  fact 
the  same  virtues  were  ascribed  to  gold  and  silver  instruments.  Skill  and  speed  on 
the  part  of  the  operator  materially  shortened  the  suffering  of  the  patient,  and  was 
made  possible  by  the  development  of  operative  technique  and  improvement  in  the 
surgical  armamentarium. 

Consequent  upon  these  additions  to  surgical  knowledge  it  is  interesting  to  note 
that  Lisfranc  advised,  whenever  possible,  to  cut  the  nerves  supplying  the  operative 
field  with  the  first  incision.  The  history  of  general  anesthesia  began  with  the  dis- 
covery of  modern  inhalation  anesthetics,  as  nitrous  oxide,  ether,  chloroform,  and 
ethyl  bromide;  the  general  use  of  these  agents,  however,  did  not  take  place  until 
some  years  later. 

Efforts  to  relieve  pain  by  local  anesthetic  agents  were  attempted  at  the  same  time 
that  experiments  were  being  made  with  general  anesthesia.  According  to  the  state- 
ments of  writers  of  ancient  and  medieval  times,  Egypt  possessed  two  such  agents. 
The  one  taken  from  the  holy  animal  of  the  land  consisted  of  the  fat  of  the  crocodile, 
or  the  dried  and  powdered  skin  of  the  same  animal.  This  was  to  be  laid  on  the  skin 
of  the  patient  and  was  supposed  to  induce  anesthesia.  We  will  make  no  mistake  in 
classing  this  with  the  religious  and  mystic  ceremonies  underlying  suggestive  therapy 
of  the  old  as  well  as  present  times.  The  other  supposed  Egyptian  agent  is  the  oft- 
mentioned  stone  of  Memphis,  which,  according  to  Plinius,  produced  local  anesthesia 
if  rubbed  on  the  skin  with  vinegar.  During  the  ^liddle  Ages  this  method  was  wrong- 
fully considered  a  means  of  inducing  general  anesthesia.  From  present  sources  of 
information  we  are  unable  to  state  what  virtues  may  be  attributed  to  this  stone. 
Littre  has  suggested  that  this  stone  was  a  variety  of  marble  which,  when  used  as  before 
mentioned,  evolved  carbon  dioxide.  Opposed  to  this  theory  is  the  fact  that  carbon 
dioxide  has  no  influence  on  the  intact  skin.  Huseman  holds  in  reference  to  the  tradi- 
tional statements  of  Pliny  and  Dioskorides  that  it  is  doubtful  if  a  "Lapis  ISIemphitis" 
was  actually  used  for  purposes  of  local  anesthesia  in  ancient  times,  as  the  translation 


HISTORY  OF  LOCAL   AXESTIIKSIA    IP    TO   THE   DISCOVERY  OF  COCAIN      19 

of  the  old  Kii'vptian  inediral  works  do  not  mention  definitely  anythin.u  regardin}; 
this  stt)ne. 

A  method  of  nnich  historic  value  devised  in  ancient  times  for  the  production  of 
local  anesthesia  was  the  compression  of  nerve  trunks.  This  accomplished  its  purpose 
without  doubt  to  a  certain  degree,  and  one  was  actually  able  by  this  means  to  per- 
form practically  the  only  operations  that  could  be  done  upon  the  extremities,  namely, 
amputations,  with  little  if  any  pain,  even  if  the  pain  occasioned  by  the  operation 
was  only  exchanged  for  the  pain  caused  by  the  compression.  This  form  of  anesthesia 
is  being  constantly  brought  up  anew^  after  all  other  methods  are  abandoned  or  for- 
gotten, only  to  be  again  given  up  on  account  of  its  serious  after-effects.  The  observa- 
tion that  patients. with  neuralgia  and  other  painful  affections  instinctively  tried  to 
lessen  their  pain  by  pressure  upon  the  affected  parts,  also  that  paralysis  occasionally 
followed  accidental  pressure  on  the  nerve  trunks;  and,  again,  the  binding  of  a  limb 
to  prevent  hemorrhage  during  amputations,  causing  disturbances  of  sensation,  were 
possibly  the  reasons  for  popularizing  this  method.  According  to  the  investigations 
of  Corradis,  the  binding  of  an  extremity  with  a  band  for  the  purpose  of  producing 
local  anesthesia  was  in  use  since  the  classical  times.  The  Arabian  physicians  likewise 
used  a  method  of  ligating  a  limb  with  the  aid  of  a  stick,  not  only  to  prevent  the  loss 
of  blood  but  also  to  reduce  pain.  In  the  sixteenth  century  Ambroise  Pare  used  this 
method  for  a  like  purpose.  In  1676  Schumann  described  the  amputation  of  a  leg  of 
a  woman  under  local  anesthesia,  praising  the  "ligatura  fortis"  both  for  its  blood- 
stilling  and  pain-reducing  qualities.  While  the  medical  onlookers  observed  the 
amputated  foot,  and  the  wound  surgeon  busied  himself  tying  up  the  part,  the  woman 
asked:    "Is  the  foot  already  off?"    She  was  happily  assured  that  all  was  over. 

Van  Swieten  and  Theden  advocated  interrupted  compression  of  the  entire  surface 
of  the  limb  by  means  of  strong  bandages.  Juvet  again  advocated  the  circumscribed 
ligation  of  a  limb  above  the  field  of  operation,  and  held  this  method  to  be  sufficient 
in  preventing  all  sensation.  On  account  of  many  failures  and  the  opposing  state- 
ments from  authoritative  sources  this  method  again  fell  into  discredit.  DeSault 
said  that  in  his  time  (beginning  of  last  century)  this  method  was  in  general  use,  but 
he  gave  it  up  as  the  ligation  of  an  extremity  carried  with  it  the  danger  of  gangrene, 
if  tied  sufficiently  tight  to  produce  anesthesia.  Thirty  years  later,  in  spite  of  these 
statements,  Liegard  again  used  this  procedure  and  described  several  toe  operations 
performed  without  pain  after  tying  off  the  leg  just  above  the  ankles.  Velpeau  also 
recommended  this  method,  having  gained  his  experience  in  operating  on  the  great 
toe.  This  method  seems  never  to  have  been  given  recognition  in  Germany.  In 
England,  J.  ]\Ioore  in  1784  attempted  to  bring  about  pressure  paralysis  of  the  sensory 
nerves  by  other  means.  He  constructed  an  apparatus  with  two  pads,  one  to  com- 
press the  sciatic  nerve,  the  other  the  anterior  crural.    He  describes  a  leg  amputation 


20  LOCAL  ANESTHESIA 

which  was  carried  out  in  this  way  without  pain,  after  the  apparatus  had  been  in  place 
for  one  and  one-half  hours,  during  which  time  the  patient  received  one  grain  of  mor- 
phine. Hunter,  who  witnessed  this  operation,  recommended  Moore's  method,  also 
B.  Bell,  who  in  fact  stated  that  it  was  the  only  remedy  suitable  for  the  lessening  of 
operative  pain.  Other  surgeons  had  no  success  with  this  method.  ]\Ialgaigne  tried 
brisement  force  on  the  knee-joint  with  the  help  of  Moore's  apparatus,  but  it  was 
found  necessary  to  interrupt  the  operation  as  anesthesia  was  not  obtained.  This 
apparatus  was  found  to  be  defective,  as  it  caused  very  severe  pain  and  intense  venous 
congestion  in  the  limb  to  which  it  was  applied.  A  sufficient  compression  of  the  crural 
nerve  was  impossible  for  anatomical  reasons,  therefore  Moore's  method  was  soon 
forgotten  and  replaced  by  the  simpler  method  of  ligation.  In  the  early  seventies 
of  the  last  century  compression  or  ligation  anesthesia  was  again  tried  by  surgeons 
of  all  lands  from  both  a  theoretical  and  practical  stand-point,  following  the  introduc- 
tion by  Esmarch  of  his  rubber  bandages  in  bloodless  surgery,  and  even  in  more  recent 
times  was  again  advocated. 

Long  after  compression  another  remedy,  also  physiological,  for  the  local  relief 
of  pain,  was  used  for  surgical  purposes,  namely,  cold.  This  was  first  introduced  about 
the  middle  of  the  sixteenth  century  by  Thomas  Bartholinus,  who  learned  of  the  pain- 
stilling  quality  of  cold  from  his  teacher,  Marco  Aurelio  Severino,  the  Neapolitan 
anatomist  and  surgeon.^ 

His  recommendations  were  later  forgotten,  three  hundred  years  passing  before 
the  chilling  of  the  tissues  was  again  used  in  surgery,  notwithstanding  repeated 
observations  made  with  this  agent.  J.  Hunter  found  by  animal  experimentation 
that  the  ears  of  rabbits  became  insensible  when  surrounded  by  a  freezing  mixture. 
Larrey,  chief  surgeon  to  Napoleon's  army,  relates  that  the  wounded  in  the  battle 
of  Eylau  (February  7-8,  1807)  requiring  amputation  had  absolutely  no  sensation 
in  their  limbs,  the  operation  being  performed  with  the  temperature  19°  below  zero. 
Another  French  military  surgeon,  Moricheau-Beaupre,  who  served  under  Napoleon 
during  the  Russian  campaign,  remarked  about  the  sedative  action  of  cold,  but  men- 
tioned no  specific  instance  in  which  cold  was  used  as  an  anesthetic.  The  chilling 
of  the  tissues  for  inducing  anesthesia  was  described  by  Arnott  (1848),  Guerard, 
llichet  (1854),  and  introduced  practically  by  Richardson.  It  is  useful  today  in  minor 
surgery  and  is  a  helping  agent  with  other  anesthetics. 

Investigating  the  experiments  as  carried  out  during  ancient  times,  it  should  be  noted 
that  various  chemical  agents,  drugs,  and  plant  remedies  were  used  in  producing  a  local 

'  Thomas  Bartholinus  states:  Antiquam  cauterio  ulcera  in  membris  excitentur,  nix  afifricata  induit 
stuporem.  Id  me  docuit  Marcus  Aurelius  Severinus  in  Gymnasio  Neapolitano  olim  preceptor  meus  et 
hospes,  Chirurgorum  hoc  saeculo  princeps.  Rectissime  autem  nivem  in  vasculum  materiae  convenientis 
capax,  sed  oblonga  ad  extremum  et  myrtiformi  specie,  conjectam,  sine  rei  ullius  interventu  applicavit. 
A  gaiigrcnoe  metu  securos  non  jussit,  medicamento  sub  angustis  paralleHs  lineis  applicato,  sensu  vero  post 
horx»  quadrantem  sopito,  secare  locum  indolentem  licebit.     (Cited  by  Kappeler). 


HISTORY  OF  LOCAL  ANESTHESIA    UP  TO   THE  DISCOVERY  OF  COCAIN     21 

analgesia.      At  the  eiul  of  the  eleventh  hook  of  the  Iliad  it  is  related  how  I'atroelus 
cut  an  arrow  from  the  back  of  the  wounded  Euripiles: 

"And  there  Patroelus  laid  him  down  and  cut 
Tlie  rankling  arrow  from  his  thigh,  and  shed 
Warm  water  on  the  wound  to  cleanse  away 
The  purple  blood,  and  last  applied  a  root 
Of  bitter  flavor  to  assuage  the  smart, 
Bruising  it  first  in  his  palms:  the  pangs 
Ceased;  the  wound  dried;  the  blood  no  longer  flowed." 

The  universal  attempts  to  induce  local  anesthesia  were  continued  by  virtue  of  a 
theory  which  existed  until  recent  times,  that  sleep-producing  drugs  would  produce 
their  peculiar  effects  when  applied  locally.  In  ancient  times  mandragora,  hyoscya- 
mus,  aconite,  and  juice  of  the  poppy  seed  and  Indian  hemp  were  in  almost  universal 
use  by  the  Hindus,  Egyptians,  Greeks  and  Romans  in  the  preparation  of  pain-quieting 
applications,  plasters,  salves,  w^ashes,  etc.  These  were  probably  used  more  by  the 
magicians  and  quacks  than  by  the  physicians,  and  were  also  used  less  as  a  prophy- 
lactic against  operative  pain  than  for  the  relief  of  painful  afflictions.  The  old  Egyp- 
tian physicians  knew  (Prosper  Alpin)  that  mixtures  of  benumbing  substances  could 
produce  local  anesthesia  for  surgical  purposes.  It  is  indeed  interesting  to  note  that 
the  Chinese  even  in  recent  times  (Porter  Smith),  after  the  discovery  of  chloroform 
and  the  knowledge  of  its  use,  applied  such  artemisian  mixtures  for  local  anesthesia 
as  the  datura  tatula,  cannabis  indica,  atropa,  and  mandragora,  drugs  described  in 
Pen-t'san-Kong-muh  by  Li-shi-chin  in  1597,  the  date  of  the  earliest  materia  medica. 
The  leaves  of  these  mixtures  were  made  into  balls  with  calamus  leaves,  placed  on 
the  painful  areas  or  operative  field  and  burned.  This  artemisia  was  so  highly  prized 
by  the  Chinese  that  with  the  defeat  of  their  fellow  tribesmen,  the  south  Asiatics 
in  Borneo,  they  were  compelled  to  pay  tribute  in  artemisian  camphor  (Koehler). 

In  the  middle  ages  we  again  meet  with  the  local  use  of  narcotic  drugs  for  the  relief 
of  pain  in  surgical  operations.  The  local  use  of  these  drugs  originated  in  the 
medical  school  of  Salerno,  which  was  the  first  to  use  narcotic  inhalations  for  similar 
purposes.  vEgidius  von  Corbeil,  a  well-known  professor  at  Salerno,  states  that  about 
the  middle  of  the  twelfth  century,  by  the  use  of  cataplasms  of  poppy,  henbane,  and 
mandrake  root  applied  to  the  skin  the  field  of  operation  could  be  rendered  insensitive.^ 

It  is  hard  to  believe  that  by  these  means  a  sufficient  amount  of  the  previously 
mentioned  drugs  could  be  absorbed  from  the  unbroken  skin  to  produce  a  useful 
anesthesia.  This  method  was  not  more  generally  accepted  than  the  oldest  anesthetic 
procedures.     In  more  recent  times  (1850)  we  have  evidence  of  similar  experiments 

'  De  Renzi,  Coll,  Salernit.,  cited  by  Husemann:  Est  quoque  notandum,  quod  papaver,  jusquiamus 
mandragora  plurinum  somnum  provocant,  unde  pro  sua  nimia  humiditate,  si  ex  his  fiat  cataplasms  et 
ponatur  loco  de  quo  debet  fieri  incisio,  vel  cyrurgia,  omnino  removebit  sensibilitatem. 


22  LOCAL  ANESTHESIA 

by  Bouisson,  who  describes  an  operation  for  unguis  incarnatus,  which  he  was  able 
to  perform  without  pain,  after  bandaging  the  toe  for  several  days  with  apphcations 
containing  opium.  The  same  idea  that  remedies  which  were  useful  in  the  artificial 
production  of  sleep  must  be  likewise  of  use  for  local  anesthesia  if  applied  to  the  skin 
is  once  again  noted  after  the  introduction  of  ether  and  chloroform  anesthesia.  This 
was  most  strikingly  stated  by  Richardson,  who  claimed  that  general  and  local  anes- 
thesia w^ere  identical  processes  brought  about  by  the  dehydration  of  the  tissues. 
Expression  was  again  given  to  these  views  in  a  quotation  by  Arans:  "Que  toutes 
les  substances  volatiles,  auxquelles  on  a  reconnu  jusqu'a  ce  jour  des  proprietes  anes- 
thesiques  generales,  possedent  egalement  des  proprietes  anesthesiques  locales,  ou 
en  application  interieur,  ou  sur  la  peau." 

Parisot  demonstrated  that  a  saturation  of  the  skin  can  readily  be  brought  about 
by  the  application  of  chloroform,  which  gave  rise  to  the  opinion  that  local  anesthesia 
could  be  more  readily  produced  with  the  volatile  inhalation  anesthetic  agents.  The 
truth  of  the  statements  has  been  partially  \Trified.  Some  of  these  substances  when 
used  in  a  gaseous  or  fluid  state  on  the  skin  produce,  after  more  or  less  severe  irritation 
or  destruction  of  tissue,  superficial  and  fleeting  disturbances  of  sensation  even  when 
the  effect  of  cold  from  evaporation  is  pre\ented.  Simpson,  Nunnelly,  Aran,  and  later 
Kappeler,  knowing  the  intense  irritating  properties  of  chloroform,  were  nevertheless 
convinced  of  its  efficiency  as  a  local  anesthetic.  Extensive  experiments  by  Witt- 
meyer  demonstrated  conclusively  that  local  anesthesia  could  be  produced  with  Liquor 
Hollandicus  (Ethylenchloride)  and  ether  hydrochloricus  chloratus  (a  mixture  of 
tri-  and  tetra-chlorethylchloride).  Experiments  along  these  same  lines  had  already 
been  carried  out  by  Wutzer,  Aran,  and  Xunnelly.  Other  inhalation  anesthetics  like 
ether  sulphuricus  and  amylen  were  ineffective  when  applied  to  the  skin.  Corning, 
in  later  experiments,  was  unable  to  produce  local  anesthesia  under  any  circumstances 
with  chloroform,  while  Bumm,  after  trying  the  preparations  recommended  by  Witt- 
meyer,  found  the  relief  from  pain  so  fleeting  and  incomplete  that  the  anesthesia  was 
insufficient  for  the  most  superficial  or  shortest  surgical  operation.  These  experiments 
were  barren  of  practical  and  useful  results  and  have  for  us  about  the  same  historic 
interest  as  the  cataplasms  of  the  professor  of  Salerno. 

We  might  next  consider  other  agents  which  w^ere  used  experimentally  in  an  effort 
to  discover  practical  methods  for  inducing  local  anesthesia,  the  value  of  which  are 
doubtful  except  in  the  minds  of  the  originators.  An  experiment  with  one  of  these 
reputed  agents  has  been  described  by  Simpson  and  Nunnelly,  who  stated  that  prussic 
acid  was  the  best  local  anesthetic,  a  belief  shared  by  many  others,  notwithstanding 
the  fact  that  no  one  carried  out  an  experiment  to  prove  the  truth  of  this  assertion. 
Simpson  finally  tried  the  method  by  placing  his  finger  in  a  glass  containing  prussic 
acid,  but  on  account  of  alarming  toxic  symptoms  was  compelled  to  discontinue  the 


HISTORY   OF  LOCAL  ANESTHESIA    UP   TO   THE   DISCOVKin'  OF  COCA/N      23 

fXlHTiment.  IVrcival  in  1772  discovered  that  under  certain  conditions  ((),  could 
I)e  used  as  a  local  anesthetic.  Later  Ewart  and  others  advised  the  use  of  earbouic 
acid  in  the  form  of  a  spray  in  cases  of  painful  ulcers.  In  1774  Ingenhous  and  Beddoes 
demonstrated  experimentally  the  sedative  effect  of  carbonic  acid  on  parts  of  the 
body  from  which  the  epidermis  had  been  artificially  removed.  Broca  and  Skinner 
tried  this  method  with  success  in  painful  affections  of  the  bladder,  and  Simpson, 
Follin,  Scanzoni.  Maisonneuve,  Monod,  and  Demarquay  in  diseases  of  the  female 
genitalia  and  various  other  surgical  conditions.  All  observers  agreed  that  carbonic 
acid  applied  to  the  intact  skin  produced  no  anesthetic  effect,  for  which  reason  it 
was  very  seldom  used  in  operative  work. 

(iuerin  advised  the  burning  of  a  small  strip  of  skin  with  ^'ienna  paste  around  the 
field  of  operation;  strange  as  it  may  seem,  this  method  was  advocated  not  during  the 
Middle  Ages  but  in  the  year  18S3. 

The  results  of  the  superficial  application  of  volatile  liquids  to  the  skin  for  the 
purpose  of  inducing  anesthesia  were  up  to  this  time  very  unsatisfactory  and  imprac- 
tical. Richardson  now  advocated  the  use  of  the  electric  current  in  aiding  the  absorb- 
tion  of  these  agents  to  w^hich  anesthetic  properties  had  been  ascribed.  In  short, 
from  numerous  observations  it  was  thought  that  the  galvanic  and  faradic  currents 
were  alone  capable  of  producing  local  anesthesia.  On  the  advice  of  Francis,  a  dentist 
from  Philadelphia,  Suerssen  and  many  others  carried  out  experiments  for  the  painless 
extraction  of  teeth,  using  electric  currents.  Foussagrives,  Bygrave,  Friedrich  and 
Knorr  used  this  method  for  similar  purposes  in  performing  minor  operations.  Their 
results  were  lauded  with  enthusiasm,  notwithstanding  the  fact  that  Nussbaum, 
von  Bruns,  Bumm  and  others  had  proved  the  absolute  uselessness  of  the  method. 
We  know  today  without  doubt  that  neither  the  induced  nor  constant  current  has 
any  effect  in  the  production  of  local  anesthesia  which  would  be  of  use  in  minor  sur- 
gical work.  Bumm  has  said:  "The  very  conflicting  statements  of  various  authors 
would  be  difficult  to  explain,  were  it  not  for  the  fact  that  one  must  always  remember 
the  self-delusion  of  the  operator  on  the  one  hand  and  the  ^'arying  or  even  untruthful 
statements  as  to  subjective  feeling  on  the  part  of  the  patient  on  the  other."  This 
statement  is  certainly  true,  for  everywhere  in  the  history  of  local  anesthesia  the  role 
of  suggestion  and  auto-suggestion  is  found  playing  a  large  part.  No  matter  how 
imperfect  a  method  of  local  anesthesia  may  be,  it  will  still  have  its  adherents.  The 
same  state  of  affairs  is  occasionally  found  today. 

Richardson's  "Voltaic  Anesthesia"  consisted  in  the  application  of  the  positive 
electrode  of  the  galvanic  current  to  the  skin,  the  sponge  of  the  electrode  being  wet 
with  the  solutions  of  the  tincture  of  aconite,  extract  of  aconite,  and  chloroform.  He 
conceived  the  idea  that  the  circulation  in  the  part  to  be  anesthetized  would  be  in- 
creased in  rapidity  from  the  irritation  of  the  galvanic  current,  and  would  therefore 


24  LOCAL  ANESTHESIA 

be  better  fitted  for  the  absorption  of  the  narcotic  drug  with  consec[iient  anesthesia. 
The  control  experiments  of  Wallers  proved  that  the  slight  insensibility  of  the  skin 
produced  by  this  means,  even  with  the  accompanying  severe  irritation,  was  due  to 
the  drug  itself  and  was  in  no  wise  dependent  upon  the  electric  current.  Much  later 
(1886)  Adamkiewicz  tried  to  aid  the  absorption  of  chloroform  by  the  skin  with 
the  cataphoric  action  of  the  electric  current.  Paschkis  and  Wagner,  and  later 
J.  Hoffmann,  demonstrated  that  cataphoresis  did  not  occur  with  the  electric  current 
used  in  connection  with  the  non-conductor  chloroform.  In  regard  to  the  newer  and 
more  fruitful  efforts  with  cataphoresis.     See  Chapter  IX. 

Anesthesia  of  mucous  membranes  by  means  of  local  applications  seems  to  have 
been  little,  if  at  all,  attempted  in  former  medical  times,  although  more  should  have 
been  expected  from  these  tissues  on  account  of  their  greater  permeability  than  from 
the  intact  skin.  Carbonic  acid  had  been  used  for  purposes  of  local  anesthesia  as 
previously  mentioned,  and  seems  to  have  been  applied  to  the  mucous  membranes 
of  the  mouth,  pharynx,  bladder,  and  female  genital  organs.  In  more  recent  times 
Brown-Sequard  mentioned  that  the  larynx  could  be  made  absolutely  insensitive  by 
allowing  a  stream  of  carbonic  acid  gas  to  play  against  the  back  part  of  the  throat 
for  a  few  minutes.  Gelle  used  with  success  applications  of  CO2  gas  to  the  external 
ear  for  relieving  earache.  Attempts  at  producing  local  anesthesia  of  mucous  mem- 
branes by  the  vapor  of  ether  or  chloroform  have  been  occasionally  noted  in  the  liter- 
ature, but  the  extensive  use  of  this  method  never  found  general  acceptance.  The 
discovery  of  the  laryngoscope  in  1857,  and  with  it  the  development  of  laryngology, 
brought  about  a  most  urgent  need  for  a  means  of  anesthetizing  the  mucous  membrane 
of  the  larynx.  In  the  year  1862  Lewin  made  the  statement  that  a  drug  for  producing 
local  anesthesia  of  the  larynx  did  not  exist.  Huette  and  Czermak  recommended 
potassium  bromide  for  the  larynx,  but  their  results  could  not  be  verified  by  Lewin, 
Scheff,  and  others.  The  results  of  Tuerck,  Bruns  and  Schroetter,  and  later  Scheff, 
in  anesthetizing  the  larynx  by  applications  of  chloroform,  concentrated  solutions  of 
morphine  with  the  addition  of  vinegar,  alcohol,  etc.,  could  likwise  not  be  substan- 
tiated. These  applications  produced  in  only  a  small  percentage  of  cases  a  tolerance 
of  the  laryngeal  mucous  membrane  to  pain,  and  were  not  without  danger  owing  to 
the  severe  irritation  of  chloroform.  In  the  use  of  morphine  in  such  large  doses, 
according  to  Harris  three-fifths  of  a  grain,  the  possibility  of  poisoning  was  always 
present.  Schroetter  in  his  early  experience  with  this  method  had  one  death  from 
morphine  poisoning.  Scheff  also  warns  against  the  repeated  painting  of  the  larynx 
with  cliloroform  and  morphine.  Tobold  never  had  satisfactory  results  with  the 
Tuerck  method,  and  it  may  be  said  that  in  all  cases  Avhere  a  satisfactory  anesthesia  of 
the  larynx  was  ol)tained,  the  result  was  due  to  the  systemic  effect  of  the  morphine. 


HISTORY  OF  LOCAL  ANESTHESLA    UP   TO   THE  DISCOVERY  OF  COCAIN      25 

This  method  finally  became  obsolete  following  the  extensive  experiments  of  ZaAver- 
thal  on  dogs,  and  further  confirmed  by  a  large  clinical  experience. 

The  discovery  by  Alexander  Wood,  of  Edinburgh,  in  1853,  of  hypodermic  injections 
by  means  of  a  hollow  needle,  is  an  important  historical  fact  in  connection  with  our 
subject.  His  discovery  was  most  important  from  the  fact  that  drugs  could  be  intro- 
duced directly  into  the  circulation.  It  also  gave  us  a  new  method  of  introducing 
different  solutions  of  drugs  into  the  tissues  so  as  to  come  into  more  intimate  contact 
with  the  nerve  supply  and  there  exert  their  chemical  or  physical  action,  something 
heretofore  impossible.  Wood  started  out  with  this  in  mind,  using  as  his  first  injec- 
tion solutions  of  morphine  and  tincture  of  opium;  this  he  injected  in  the  neighbor- 
hood of  nerve  trunks  for  the  purpose  of  utilizing  the  local  anesthetic  properties 
of  the  drug  for  the  relief  of  neuralgic  pain.  Morphine  and  opium  were  chosen  for  the 
purpose  owing  to  the  prevailing  idea  that  sleep-producing  drugs  exerted  their  action 
at  the  site  of  injection.  The  injection  of  solutions  of  morphine  to  obtain  local 
anesthesia  in  minor  operations  was  used  with  partial  success  in  the  following  year 
for  the  removal  of  toe-nails,  cauterization  of  wounds,  and  ulcers.  In  some  cases 
results  were  no  doubt  due  to  the  systemic  effect  of  the  morphine,  as  in  a  case  of 
Jarotzky  and  Zulzer,  where  the  strapping  of  a  testicle  with  adhesive  plaster  was  done 
without  pain;  likewise  Walker  was  able  to  employ  taxis  in  a  case  of  strangulated 
hernia,  and  succeeded  in  reducing  it  without  pain,  following  the  injection  of  1  grain 
(0.06)  of  morphine.  Eulenburg  injected  |  grain  of  morphine  in  each  side  of  the 
exit  of  the  superior  laryngeal  nerve,  through  the  thyrohyoid  membrane,  and  was 
enabled  in  this  way  to  produce  an  absolute  anesthesia  of  the  larynx.  Much  later 
(1880)  this  same  procedure  was  described  by  Rossbach,  but  control  experiments  by 
others  were  without  results.  Tobold,  according  to  Eulenburg,  found  that  sensation 
of  the  upper  part  of  the  larynx  was  diminished  by  these  injections,  but  anesthesia 
sufficient  for  operation  could  not  be  produced.  Chloroform  injections  were  used 
for  purposes  of  local  anesthesia  by  C.  H.  Hunter,  but  were  given  up  because  the  pains 
from  the  injections  was  far  more  severe  than  those  from  the  operation.  Pelikan 
and  Koehler,  the  latter  with  great  reserve,  however,  advocated  the  use  of  the  glucoside 
saponin  subcutaneously  for  the  production  of  local  anesthesia,  but  the  severe  pain 
due  to  this  irritating  drug,  as  observed  by  Eulenburg,  Keppler,  and  Kappeler,  pro- 
hibited its  further  use.  The  use  of  physiological  solutions  of  proper  temperature 
injected  into  the  tissues  for  the  purpose  of  dehydrating  them,  and  causing  them  to 
swell,  belongs  to  more  recent  times  and  will  be  described  later. 

It  will  be  seen  from  the  preceding  historical  sketch  how  earnest  were  the  constant 
efi'orts  made  during  the  past  for  a  useful  local  anesthetic.  After  the  introduction  of 
general  anesthesia  these  efforts  were,  if  anything,  carried  on  with  greater  zeal.  In 
preanesthetic  days  surgical  operations  were  always  associated  with  pain  in  the  minds 


26  LOCAL  ANESTHESIA 

of  both  physician  and  patient,  but  with  the  advent  of  anesthesia  these  conditions 
changed.  Patients  now  demanded  that  operations  be  carried  out  without  pain  under 
general  anesthesia,  although  the  method  was  hazardous.  On  account  of  this  danger 
the  desire  still  prevailed  to  find  a  method  of  painless  operating  without  the  drawbacks 
of  general  anesthesia.  The  approach  to  our  subject  takes  us  back  again  to  the  history 
of  ancient  times  where  the  means  to  the  end  had  already  been  indicated.  In  every 
possible  manner,  both  physiological  and  chemical,  attempts  were  made  to  influence 
sensation  in  the  nerve  trunks  or  their  endings  for  the  production  of  local  anesthesia, 
by  the  use  of  cold,  compression,  and  drugs  of  all  kinds.  Drugs  were  applied  to  the 
skin  and  mucous  membranes,  their  absorption  being  aided  by  the  electric  current, 
or  they  were  injected;  yet  the  only  method  of  use  handed  down  to  modern  times 
was  the  application  of  cold.  The  efforts  to  discover  an  efficient  chemical  anesthetic, 
which  was  the  punctum  saliens,  failed  completely,  and  until  the  discovery  of  such 
drugs,  local  anesthesia  was  without  tangible  form.  The  new  era,  therefore,  began  in 
1S84  with  the  introduction  of  cocaine,  which  in  its  physiological  reactions  differed 
from  all  heretofore  known  substances.  The  history  of  local  anesthesia  was  in  the 
following  years  synonymous  with  cocaine  anesthesia  and  will  be  considered  in  another 
chapter. 


chapter  ii. 

sexsatiox  and  pain— anesthesia  and  anesthetic 
.aip:thods. 

The  ability  of  the  living  body  to  react  to  stimuli  affecting  its  nervous  elements 
so  as  to  cause  reflexes,  perception,  feeling  or  conception,  is  termed  sensation.  The 
senses  of  feeling,  hearing,  smelling,  tasting  and  seeing,  likewise  pressure,  temperature, 
and  muscle  senses,  allow  us  to  appreciate  the  condition  of  our  surroundings  as  well 
as  the  nature  of  our  own  bodies,  but  what  interests  us  particularly  in  this  connection 
is  the  subject  of  pain.  Pain  is  a  sensation  feared  by  man,  the  alleviation  of  which 
is  being  constantly  attempted  by  the  physician.  It,  however,  acts  as  a  conservator 
of  the  species  by  giving  evidence  of  illness  in  the  human  body.  Pain  from  injury 
gi\es  evidence  of  threatened  danger  from  without  which  can  still  be  avoided,  or 
that  damage  to  the  body  has  already  taken  place  requiring  immediate  attention  to 
prevent  more  serious  consequences.  Pain  acts  as  a  monitor,  warning  us  of  improper 
ways  of  living  which,  if  continued,  will  interfere  with  the  general  health.  It  precedes 
or  accompanies  the  outbreak  of  disease  and  warns  one  that  the  body  is  sick  and  needs 
attention.  Pain  due  to  physical  or  mental  overwork  requires  rest  and  recreation. 
The  patient  seeks  to  protect  a  painful  organ  causing  symptoms  in  a  definite  dis- 
eased part  of  the  body.  Pain  is  the  best  assistant  of  the  physician.  The  sick  follow 
its  instructions  obediently,  and  demand  definite  advice  for  correct  living  from  their 
medical  advisers.  Nature,  by  means  of  pain,  compels  even  the  most  active  to  rest, 
the  most  wilful  to  obser\e  proper  living  conditions  for  the  diseased  body.  Pain  is 
a  se\-ere  but  necessary  law  of  nature,  but  like  all  her  laws  is  undeviating  in  its  course, 
insensible  in  its  regard  to  feeling,  appearing,  therefore,  brutal  and  grewsome.  It 
appears  not  only  as  a  beneficent  monitor  but  also  as  a  useless  tormentor.  In  incu- 
rable diseases,  also  in  affections  which  though  understood  we  are  unable  to  influence, 
pain  occurs  and  takes  away  unsparingly  the  pleasures  of  life  without  offering  any 
bodily  advantage  in  return  (Goldscheider).  Pain  is  often  absent  in  the  most  dan- 
gerous diseases,  thus  giving  the  patient  false  assurance.  It  is  present  and  must  be 
relieved  by  the  physician  whenever  the  patient  undergoes  operation.  It  is  certainly 
the  duty  of  the  physician  to  attempt  the  relief  of  pain.  That  it  is  not  to  be  banished 
from  the  world  is  a  certainty,  in  fact  we  would  not  wish  it  otherwise.  Pain  is  neces- 
sary not  only  for  guarding  us  in  the  fight  against  the  forces  of  disease,  but  also  as  a 


28  LOCAL  ANESTHESIA 

monitor  of  our  emotions,  for  in  the  recollection  of  pain  either  bodil}-  or  mental  lies 
in  large  part  the  cause  of  compassion  and  the  helpful  love  of  mankind  (Goldscheider). 

Pain  sense  like  all  the  other  senses  is  associated  with  the  functioning  of  the  cortex 
of  the  brain.  According  to  Flechsig  the  pain-transmitting  fibers  end  in  the  cortical 
sensory  area,  the  latter  corresponding  in  part  to  the  cortical  motor  area.  By  inter 
rupting  fibers  from  the  corona  radiata,  in  the  region  between  the  anterior  and  pos- 
terior ends  of  the  thalamus,  complete  anesthesia  is  produced  on  the  opposite  side 
of  the  body  (Tuerck's  hemianesthesia).  Flechsig  believes  that  the  centre  for  pain- 
ful impressions  is  located  in  a  different  area  of  the  sensory  cortex  than  the  sense  of 
touch,  probably  in  the  forniculate  gyrus.  Painful  sensations  following  irritation 
are  probably  conveyed  to  the  brain  through  the  peripheral  sensory  nerves  of  the 
brain  and  cord.  In  the  cord  it  is  generally  believed  that  painful  impressions  are 
transmitted  through  the  gray  matter.  Whether  the  sympathetic  nervous  system 
can  receive  and  transmit  painful  impressions  is  doubtful. 

A  suitable  irritant  (mechanical,  chemical,  thermic,  or  electrical)  can  produce 
pain  equally  as  well  when  affecting  the  end  organs  as  when  affecting  the  nerve  in  its 
course.  The  former  painful  sensation  appears  to  be  much  more  severe  than  the  latter. 
It  has  been  demonstrated  by  the  surgeon  that  the  brain,  at  least  on  its  convex  surface, 
is  absolutely  insensitive  to  pain  or  pressure.  In  this  respect  this  pain  centre  is 
like  controlling  the  special  senses,  because  it  has  been  fonnd  that  direct  irri- 
tation of  the  brain  centres  controlling  the  special  senses  does  not  produce  impres- 
sions of  light,  hearing,  etc.  For  the  brain  to  become  responsive  it  seems  necessary 
that  the  irritant  must  be  transformed  in  some  way  by  the  outer  sense  organs.  Clin- 
ical experience  seems  to  prove  that  neither  the  brain  nor  cord  has  pain  sense.  Painful 
impressions  produced  upon  the  cerebral  cortex  are  projected  from  the  brain  to  various 
parts  of  the  body,  likewise  irritation  of  a  sensory  nerve  trunk  produces  its  effect  in 
the  area  of  distribution  of  the  nerve.  If  the  trunk  of  the  ulnar  nerve  is  pricked  at 
the  elbow  with  a  fine  needle,  sensation  or  paresthesia  will  be  experienced  in  the  fourth 
and  fifth  fingers;  the  feeling  may  be  that  of  pressure,  temperature  change,  or  pain. 
A  second  pain  will  now  be  experienced  at  the  point  of  irritation,  and  inasmuch  as 
this  nerve  trunk  has  no  local  branches,  this  feeling  of  pain  must  be  transmitted  to 
the  brain  by  the  nervi  nervorum  (Goldscheider).  The  localization  of  painful 
impressions,  as  is  well  known,  is  very  often  uncertain  and  gives  rise  to  various  errors. 
Pain  in  a  definite  part  of  the  body  or  in  a  certain  organ,  can  originate  in  this  part  or 
organ,  or  be  due  to  the  stimulation  of  its  conducting  nerves  or  the  brain  itself. 
Although  the  brain  is  apparently  insensitive  to  ordinary  stimuli,  there  is  no  doubt 
that  pain  is  often  not  peripheral  but  of  central  or  cortical  origin. 

It  is  still  undecided  whether  pain  is  produced  by  a  specific  action  of  the  senses, 
or  whether  the  conducting  nerves  are  associated  in  their  course  with  particular  end 


SENSATION  AND  PAIN— ANESTHESIA  AND  ANESTHETIC  METHODS       29 

organs.  The  most  gentTally  accepted  theory  is  that  of  (loldsclieidcr,  who  chtiiiis  that 
pain  is  produced  by  excessive  irritation  of  the  usual  centripetal  nerves  of  pressure 
and  common  sensation.  Pain  and  pressure  sensations  are  not  different  varieties, 
but  due  merely  to  a  difference  in  degree  of  the  irritant;  with  slight  stimulation,  the 
feeling  of  pressure  occurs,  while  a  greater  degree  of  irritation  produces  pain.  Frey 
opposes  this  theory  and  holds  strongly  to  the  existence  of  special  nerves  of  pain, 
ha^-ing  their  end  organs  in  the  intra-epithelial  cells  of  the  skin.  Both  of  the  above 
theories  are  supported  by  actual  observations  and  clear-cut  reasoning,  but  to  decide 
between  them  would  be  out  of  place  at  this  time,  except  to  say  that  in  certain  clinical 
cases  of  disease  of  the  brain  or  cord  associated  with  isolated  paralysis  of  the  senses 
of  feeling  or  pain,  it  would  be  very  difficult  to  explain  these  conditions,  if  we  did  not 
believe  in  the  existence  of  separate  tracks  and  end  organs.  The  experiencing  of 
excessive  pain  from  irritation  is  called  hyperalgesia;  a  diminution  of  pain  sense  is 
termed  hypalgesia.  Hyper-  and  hypalgesia  are  very  often  of  central  or  pyschical 
origin.  The  expression  and  degree  of  pain  varies  greatly  with  the  individual  and  is 
influenced  by  innumerable  circumstances,  such  as  character,  breeding,  the  intelli- 
gence of  the  individual,  his  general  conception  of  things,  nationality,  age,  sex,  and 
general  physical  condition. 

The  out\vard  expression  of  pain  is  of  course  no  guide  as  to  its  actual  intensity,  as 
pain  is  largely  dependent  upon  the  psychical  condition  of  the  patient.  A  sudden 
unexpected  injury  of  the  body  is  not  found  to  be  painful;  a  needle-prick  is  painful 
when  expected.  If  the  mind  is  otherwise  occupied  no  pain  is  felt.  Kant  was  able 
to  intentionally  concentrate  his  mind  on  certain  themes,  so  as  not  to  feel  the  pains 
of  gout  from  which  he  was  suffering.  The  thought  of  pain,  or  better,  the  fear  of  pain, 
as  we  are  really  not  able  to  imagine  severe  pain,  increases  its  intensity.  Strong-minded, 
intelligent  persons  give  less  expression  of  pain  than  weaker  or  less  intelligent  ones; 
the  latter  will  feel  pain  where  others  would  not.  The  tolerance  of  pain  varies  with 
the  epochs  of  time  and  the  class  of  people.  Those  of  the  hard  and  grewsome  IVIiddle 
Ages  were  less  sensitive  than  those  of  the  modern  world  of  culture;  even  today 
the  uncivilized  races  are  less  sensitive.  We  cannot  compare  the  atrocities  of  the 
^liddle  Ages  and  those  existing  among  certain  tribes  of  the  present  day,  or  the  cas- 
tigation,  self-mutilation,  or  self-offering  of  Christian  and  heathen  fanatics  with  our 
conception  of  pain.  We  need  have  no  sympathy  with  the  actor  who  in  public  allows 
needles  to  be  stuck  into  his  body,  as  appreciation  of  pain  is  entirely  lacking  in  him. 
]Mucius  Scaevola,  who  in  a  moment  of  intense  excitement  thrust  his  hand  into  the 
fire,  did  not  suffer  to  the  same  extent  as  an  individual  compelled  to  do  a  certain  act. 
People  of  the  North  seem  to  be  less  sensitive  than  those  of  the  South;  city-bred  are 
more  sensitive  than  the  majority  from  the  country,  while  old  persons  are  more  tolerant 
than  those  in  the  prime  of  life.     The  physician,  and  more  particularly  the  surgeon, 


30  LOCAL  ANESTHESIA 

meets  with  these  physical  variations  of  sensation  ahnost  daily  and  he  mnst  know 
beforehand  what  demands  he  can  make  on  the  patient  to  be  operated  upon  without 
an  anesthetic.  Certain  it  is  that  the  conduct  of  patients  during  painful  procedures 
is  often  only  a  variation  in  the  outward  expression  of  pain;  nevertheless  we  must 
assume  that  in  certain  individuals  and  some  races  the  physiological  pain  sense  is  less 
highly  developed  than  in  others.  In  the  newborn  the  pain  sense  is  only  slightly 
developed,  it  being  very  probable  that  this  sense  is  developed  later  in  life  and  to  a 
varying  extent  just  as  the  other  senses  are  developed.  How  and  in  what  form  hyper- 
esthesia and  hypesthesia  occur  in  diseases  of  the  brain  and  cord  we  will  not  discuss 
at  this  time. 

Peripheral  causes  can  produce  an  aggravation  or  lessening  of  pain.  The  pain 
sense  of  organs  or  tissues,  when  the  latter  are  subject  to  disease,  is  often  increased, 
seldom  diminished.  Acute  inflammation  and  fluids  confined  under  pressure  give 
rise  to  spontaneous  pain  and  often  excessive  hyperesthesia.  The  fact  that  an  organ 
in  health,  without  feeling  and  under  pathological  conditions,  suddenly  becomes 
painful  is  difficult  if  at  all  possible  of  explanation.  The  ability  to  receive  and 
transmit  painful  impressions  to  the  brain  must  be  present  in  the  healthy  state  if 
disease  can  increase  it.  It  might  also  be  mentioned  that  local  disturbances  of 
nutrition,  such  as  chronic  edema,  can  diminish  the  sensibility  of  a  part;  the  cause 
is  probably  to  be  found  in  the  fact  that  the  physical  and  chemical  composition  of 
the  edema  fluid  is  different  from  the  normal  nutritive  fluids  so  necessary  for  the 
correct  functioning  of  nervous  elements. 

Of  no  small  importance  for  local  anesthesia  is  the  distribution  of  pain  sense  in  the 
different  organs  and  tissues.  It  is  certain  that  organs  have  parts  of  marked  sensi- 
bility, areas  of  diminished  sensation,  and  in  places  absence  of  feeling.  To  arrive 
at  positive  conclusions  is  not  easy,  as  experiments  would  have  to  be  conducted  on 
living  human  beings.  Then  again  we  possess  no  means  of  measuring  the  intensity  of 
pain.  We  are  largely  dependent  for  facts  of  this  kind  upon  experience  gained  in  oper- 
ating upon  the  unanesthetized  patient.  In  more  recent  times  Bloch  and  Lennander 
have  investigated  this  subject  and  collected  what  little  there  was  to  be  found  in 
the  old  literature.  The  observations  of  Bloch  are  rather  misleading  and,  therefore, 
objectionable  because  they  were  made  among  a  people  apparently  very  insensitive  to 
pain,  and  were  carried  out  under  the  suggestive  influence  of  the  operator,  and  in 
many  cases  small  doses  of  chloroform  were  given  sufficient  to  bring  about  the  so-called 
stage  of  analgesia.  Some  few  observations  are  noted  by  Schleich  and  others  in  their 
works  on  surgery  and  local  anesthesia. 

The  skin  with  its  innumerable  nerve  endings  can  be  said  to  be  the  most  sensiti^•e 
tissue  in  the  body.  In  olden  days  wdien  amputations  and  herniotomies  were  per- 
formed without  general  or  local  anesthesia,  patients  complained  most  when  the  skin 


SEXSATIOX  AM)  I'AIX—AXKSTHJ'JSIA    AM)  AXKSTUKTIC   METHODS       31 

was  cut,  while  the  balance  of  the  operation  was  comparatively  free  from  pain  (Mont- 
falcon).  Bloch  cites  numerous  proofs  to  support  the  fact  that  many  operations  are 
easily  borne  if  the  skin  alone  is  rendered  insensitive.  Pain  perception  in  the  skin  is 
not  evenly  divided  over  the  surface  of  the  body;  the  skin  of  the  back,  for  instance, 
being  much  less  sensitive  than  that  of  the  finger  tips;  the  extensor  surfaces  of  limbs 
being  in  general  less  sensitive  than  the  flexor  surfaces.  In  disease,  particularly  the 
acute  inflammations,  the  skin  becomes  extremely  sensitive,  so  that  the  slightest 
touch,  in  fact  every  manipulation  in  the  region  of  the  inflamed  area,  is  very  painful. 

The  loose  subcutaneous  connective  tissue  possesses  very  little,  and  at  times  no 
feeling,  though  numerous  conducting  nerves  containing  sensory  fibers  for  the  skin 
tra\-erse  this  area.  These  nerves  are  frequently  connected  with  the  bloodvessels, 
and  are  contained  in  strong  connective  tissue  sheaths.  The  larger  the  nerve  trunks 
the  more  deeply  they  are  situated,  usually  in  the  region  of  the  fascia.  Pain  of  vary- 
ing intensity,  depending  upon  the  location  and  individual,  is  often  produced  by 
cutting,  pressing,  or  pulling  on  the  nerves  in  the  subcutaneous  tissue  with  hooks  or 
other  instruments,  or  in  picking  up  and  tying  bloodvessels.  The  nerve  distribution 
in  muscle  is  practically  the  same  as  that  in  connective  tissue.  In  operating  upon 
unanesthetized  patients  one  finds  in  the  numerous  connective  tissue  septa  of  the 
muscle  bundles  many  areas  painful  to  mechanical  irritation;  these  correspond  to 
sensory  nerve  tracks.  Sticking  a  needle  in  the  muscle  of  a  healthy  person  is  in  most 
situations  free  from  pain,  but  if  one  of  the  sensory  tracks  is  touched  by  the  needle 
pain  promptly  occurs.  Tendon  tissue  appears  to  be  without  feeling,  as  can  be  readily 
demonstrated  during  tendon  suture;  however,  the  connective  tissue  surrounding 
tendons,  tendon  sheaths,  muscle  fascia,  and  the  associated  layers  of  connective  tissue, 
possess  a  varying  degree  of  pain  sense  due  in  all  probability  to  nerve  endings  in  these 
parts.  Besides  observations  made  during  operations  upon  injured  parts,  one  can 
readily  demonstrate  these  facts  upon  his  own  body.  Use  for  this  purpose  a  very 
fine  steel  needle.  This  is  passed  through  the  skin  into  the  underlying  connective 
tissue  in  any  part  of  the  body,  after  first  making  the  skin  insensitive  by  the  for- 
mation of  a  wheal  in  the  manner  to  be  described  later,  so  that  the  skin  sensation 
can  be  excluded.  The  needle  can  be  moved  in  all  directions  parallel  to  the  skin 
surface  and,  as  a  rule,  no  pain  is  felt.  Only  in  certain  places  where  the  needle 
encounters  nerve  trunks  will  there  be  sensations  of  paresthesia  or  pain.  The  needle 
is  now  passed  perpendicularly  into  the  deeper  parts  and  as  soon  as  it  comes  in  con- 
tact with  the  muscle  fa.scia  or  the  surrounding  connective  tissue,  pain  is  experienced, 
as  a  rule  not  excessive;  in  some  few  places  there  seems  to  be  an  absence  of  sensation. 
This  pain  is  fairly  well  localized.  Sensations  other  than  pain,  such  as  pressure 
or  touch,  are  never  produced  in  fascia;  likewise  sensations  of  paresthesias  which 
are  characteristic  of  the  irritation  of  nerve  trunks  going  to  the  skin,  never  occur. 


32  LOCAL  ANESTHESIA 

Pain  of  a  like  character  is  felt  when  the  needle-point  touches  the  surface  of 
tendons  such  as  the  tendo-Achillis.  The  transfixing  of  this  tendon  is  painless,  yet 
when  the  needle  emerges  upon  the  opposite  surface  the  pain  is  again  felt.  The  sen- 
sation is  always  one  of  pain,  and  never  any  other.  Tenotomy  of  the  tendo-Achillis 
with  only  anesthesia  of  the  skin  is  for  most  persons  a  very  painful  operation,  even 
though  contrary  to  the  experiments  of  Bloch. 

Periosteum,  according  to  Haller,  Piory,  and  Bloch,  possesses  no  pain  sense,  at  least 
in  the  healthy  state.  This  appears  rather  extraordinary  considering  the  richness  of 
its  nerve  supply.  This  assumption  is  certainly  not  correct,  for  if  the  periosteum  of  a 
healthy  person  is  tested  in  the  manner  before  described,  places  will  be  found  where 
it  is  extremely  sensitive.  The  anterior  surfaces  of  the  tibia,  ribs,  patella,  and  alveolar 
processes  have  scarcely  any  point  which  is  not  as  sensitive  as  the  skin  itself,  the  pain 
being  fairly  well  localized.  On  the  posterior  surface  of  the  tibia  and  the  outer  sur- 
faces of  the  femur,  radius,  and  fibula,  experiments  will  demonstrate  that  painful  areas 
are  much  less  numerous,  and  there  are  places  between  the  painful  areas  where  the 
needle  produces  no  localized  sensation.  It  appears  that  the  pain  was  felt  only 
after  severe  prodding  with  the  needle  so  as  to  jar  the  entire  bone.  Throughout  this 
structure,  moreover,  no  other  sensation  than  pain  is  produced  by  irritation  of  either 
periosteum  or  bone.  In  head  injuries  with  exposure  of  periosteum,  tests  of  this  mem- 
brane or  attempts  at  stripping  same  from  the  bone,  are  without  exception  very  painful. 
Sensitiveness  of  the  periosteum  of  the  jaw  is  a  daily  observation,  the  degree  of 
sensitiveness  as  in  all  other  parts  being  in  large  measure  influenced  by  the  place 
and  the  individual.  In  general,  therefore,  the  periosteum  must  be  considered  a  very 
sensitive  structure  even  under  normal  conditions.  Lennander's  observations  coincide 
with  these  findings. 

In  regard  to  the  pain  sense  of  bone  or  its  marrow,  the  following  should  be  noted: 
Montfalcon  says  that  patients  undergoing  amputations  complain  bitterly  of  pain 
on  cutting  the  skin,  less  on  cutting  muscle,  and  not  at  all  on  sawing  the  bone.  Piorry, 
on  the  contrary,  claims  that  the  medulla  of  bone  in  sawing,  passing  sounds,  or  on  the 
injection  of  irritating  fluids,  is  extremely  painful.  Reid  in  describing  amputations 
under  local  anesthesia  claims  that  a  sharp  narcosis  is  necessary  in  sawing  through 
the  bone.  Schleich  also  claims  that  the  bone  and  medulla  are  sensitive.  According 
to  the  observations  of  Bloch,  in  amputations  and  chisel  operations  the  medulla  has 
sensation,  but  no  pain  sense.  The  cases  in  proof  of  this  assertion  are  not  very  strong 
evidence  as  they  were  carried  out  under  light  chloroform  anesthesia.  Bichat, 
quoted  by  Bloch,  claims  that  pain  sense  is  more  marked  in  the  central  part  of  the 
diaphysis  of  long  bones  than  toward  the  epiphysis.  The  medulla  of  short  and  flat 
bones  is  less  sensitive. 

This  is  certain:  bone  receives  the  sensory  supply  which  it  undoubtedly  possesses 


SENSATION  AND  PAIN— ANESTHESIA   AND  ANESTHETIC  METHODS      33 

from  the  i)eriosteuni.  If  the  i)cru)st(Mini  is  coniplctt'ly  separated  from  the  bone, 
or  rendered  insensitive  by  artifieial  means,  the  bone  in  this  location  and  in  its 
entire  cross  section  becomes  absolutely  insensitive.  In  partial  removal  of  peri- 
osteum, the  bone  thus  uncovered  is  painless  and  can  be  chiseled.  The  medulla  of 
bone,  according  to  Schleich  is  not  free  from  pain  sense,  and  he  thought  it  necessary 
to  anesthetize  it.  Piorry's  observations  in  sounding  bone  sinuses  indicated  that  the 
medulla  was  painful.  This  is  not  correct,  according  to  recent  observations  made  on 
large  cavities  in  the  tibia,  the  anterior  wall  of  which  had  been  destroyed  by  osteo- 
myelitis, although  the  periosteum  of  the  posterior  surface  of  the  bone  was  retained. 
Painful  sensations  were  only  experienced  in  a  few  places  in  the  bone,  and  not  of 
se^-ere  degree.  Such  bone  cavities  can  be  curetted,  and  only  when  the  periosteum  at 
the  margin  of  the  ca^•ity  is  touched  does  the  patient  complain  of  severe  pain.  Other 
sensations  than  pain  are  not  observed  in  such  a  bone;  pressure  and  temperature 
senses  are  positively  absent.  Only  the  shaking  of  the  entire  bone  or  extremity  is 
felt,  wliich  is  probably  due  to  the  change  of  position. 

Cartilage  is  insensitive  (Bloch,  Lennander),  while  perichondrium,  when  present, 
is  rich  in  nerves  and  is  undoubtedly  sensitive  to  pain. 

Joint  capsules,  ligaments,  and  synovial  membranes  usually  require  to  be  anesthet- 
ized before  operation.  The  sensitiveness  of  synovial  membranes  is  very  pronounced, 
even  in  uninflamed  conditions,  which  is  certainly  to  be  expected  in  consideration  of 
their  ample  nerve  supply.  The  injection  of  irritating  fluids  into  a  joint  is  usually  very 
painful;  also  in  arthrotomy  of  the  knee-joint  the  synovia  was  found  very  sensitive. 
Joint  capsules  and  ligaments  contain  nerve  tracts  which  cause  more  or  less  pain 
on  pulling  or  cutting.  Haller  states  that  ligaments  and  capsules  are  insensitive; 
according  to  Bloch,  no  one  tissue  of  a  joint  possesses  marked  pain  sense.  The  example 
which  Bloch  gives  among  others  to  prove  the  truth  of  his  assertion  is  as  follows: 
Girl,  aged  twenty-nine  years,  suffering  from  a  chronic  ostitis  of  the  external  condyle 
of  the  femur.  An  Esmarch  band  was  applied,  ethyl  chloride  sprayed  on  the  skin, 
after  which  an  incision  G  cm.  long  was  made  without  pain.  The  knee-joint  was  opened 
and  its  interior  probed  in  all  directions  to  determine  its  sensibility.  The  periosteum 
was  separated  from  the  external  condyle,  and  the  diseased  bone  area  was  removed 
with  chisel  and  curette.  The  operation  lasted  eleven  minutes;  the  patient  experienced 
no  pain,  which  cannot  be  ascribed  to  the  ligation  of  the  extremity,  owing  to  the  short 
time  required  for  the  operation.  A  similar  example  of  a  painless  operation  may  be 
noted:  On  July  7,  1899,  a  laboring  man  was  operated  upon  for  a  pseudoarthrosis 
of  the  ulna.  Except  that  he  was  slightly  excited  his  nervous  system  was  perfectly 
healthy.  The  skin  incision  was  made  after  infiltration  with  cocain,  the  bone  was 
exposed,  periosteum  separated,  the  connective  tissue  between  the  bone  ends  was 
excised,  the  bone  ends  freshened  and  sutured  with  wire,  and  the  wound  closed  with 
3 


34  LOCAL  ANESTHESIA 

sutures.  The  patient  felt  no  pain  during  the  entire  operation,  lasting  one  hour 
and  a  half. 

October  19,  the  operation  was  repeated  without  an  anesthetic  of  any  kind,  as  bony 
union  had  not  taken  place.  The  operation  was  again  performed,  without  pain  accord- 
ing to  the  statements  of  the  patient.  The  question  of  anesthesia  in  cases  of  this  kind 
can  be  readily  explained,  for  whether  the  skin  is  deadened  with  ethyl  chloride  or  not, 
the  patient  does  not  complain  and  does  not  feel  the  pain  of  operation.  To  generalize 
from  such  experiences,  which,  no  doubt,  all  surgeons  have  had,  is  not  possible,  and 
to  use  such  patients  for  studying  sensation  is  of  no  value.  It  is  scarcely  worthy 
of  consideration  to  believe  that  the  tissues  before  mentioned,  innervated  by  the 
cerebrospinal  nerves,  can  develop  a  high  grade  of  pain  sense  in  consequence  of  an 
acute  inflammation  or  a  central  or  physiological  hyperesthesia,  and  under  ordinary 
conditions  be  free  from  pain. 

The  mucous  membranes  of  the  mouth,  nose,  and  pharynx  are  all  more  or  less  sen- 
sitive to  pain  in  the  healthy  state;  this  can  likewise  be  said  of  the  mucous  membrane 
lining  the  antrum  of  Highmore,  the  frontal  sinuses,  and  tympanic  cavity. 

We  encounter  now  for  the  first  time  a  truly  insensitive  organ,  namely,  the 
mucosa  of  the  stomach  and  intestinal  tract.  Absence  of  sensation,  even  in  the 
most  sensitive  persons,  begins  in  the  esophagus,  the  swallowed  morsel  being 
lost  to  sensation  as  soon  as  it  passes  the  pharynx.  This  lack  of  sensation  extends 
to  the  rectum,  painful  sensation  again  appearing  in  this  part  and  becoming  most 
pronounced  in  the  anal  portion.  The  absolute  lack  of  sensation  of  the  mucous  mem- 
brane of  the  colon  to  mechanical,  chemical,  and  thermic  irritation  was  observed  by 
Steinhaeuser  in  1S31,  and  can  be  readily  demonstrated  on  the  anus  preternaturalis 
when  fixed  to  the  anterior  abdominal  wall,  or  after  excision  of  the  rectum;  on  the 
sigmoid,  fixed  either  to  the  anal  or  sacral  region.  These  experiments  were  carried  out, 
among  others,  by  Bloch  and  Lennander;  the  author  has  also  been  able  to  demonstrate 
the  insensitiveness  of  the  sigmoid  years  after  the  excision  of  the  rectum.  The  sensi- 
bility of  the  abdominal  organs  will  be  considered  again  later.  The  degree  of  pain 
sense  in  the  larynx  does  not  seem  to  be  very  pronounced,  but  it  is  difficult  to  deter- 
mine, owing  to  the  highly  developed  reflexes  in  this  organ.  Foreign  bodies  in  the 
larynx,  or  a  diseased  condition,  only  cause  severe  pain  when  producing  pressure 
on  the  i)erich()ndrium.  The  tracheal  mucosa,  according  to  Bloch  and  Lennander, 
is  insensitive. 

The  urethral  mucous  menilirane  under  normal  conditions  is  very  sensitive, 
though  Bloch  declares  the  cutting  of  the  urethral  orifice  to  be  but  slightly  painful. 
This  statement  will  be  borne  out  by  \ery  few  patients.  \Yhether  the  pain  following 
the  stretching  of  the  urethra  occurs  in  the  mucous  membrane  is  questionable. 
The  mucous    membrane  of    the  normal    l)Iadder    is  but  slightly  sensitive,  in  fact 


'i 


SKXSATIOX   AM)   I'AIX  -.\.\I':STIII':SIA    AM)   AXKSTIl ETIC   METHODS       35 

parts  arc  found  without  sensation.  Hlocli  rc])ortc(l  on  opening;-  the  bladder  l)y 
s(>etio  alta,  that  the  inHanu>d  niucoiis  membrane  at  the  fun(his  was  insensitixc,  whih' 
that  at  \\\v  neck  of  the  bhid(U'r  was  ([iiite  tender.  Siiprai)ul)ie  cystotomy  is  fre(|uently 
performed  today  un(UT  h)eal  anesthesia,  and  has  demonstrated  that  the  l)hulder 
mucosa  is  t>\erywhere  more  or  k'ss  sensiti\e  and  recjuircs  to  be  anesthetize(h  The 
mucous  membrane  of  the  introitus  vagina?  is  extremely  sensiti\e,  that  of  the  vagina 
\ery  much  less  so,  notwithstanding  Lennander's  claim  that  the  \agina  is  insensitive. 
The  mucous  membrane  of  the  uterus  is  only  sHglitly  sensitive. 

Another  organ  which  gives  al)solutely  no  reaction  to  outside  stimuli  is  the  brain. 
As  has  already  l)een  stated,  clinical  experience  with  diseases  of  the  brain  does  not 
sustain  the  assumption  that  this  organ  has  any  pain  sense.  Observations  by 
surgeons  have  established  the  fact  that  at  least  the  convexity  of  the  hemispheres  is 
insensitive.  On  two  occasions  this  observation  was  made  with  patients  who  were 
perfectly  conscious;  the  first  was  a  patient  in  whom  an  abscess  was  opened  in  the 
motor  area,  because  it  was  thought  in  this  instance  that  the  abscess  was  deeply  located 
in  the  hemisphere  on  account  of  persistent  temperature;  the  other  observation 
was  made  during  a  secondary  operation  on  a  patient  with  a  bone  defect  in  the 
skull,  when  recurrence  was  expected  following  the  removal  two  years  liefore  of  a 
gliomatous  brain  cyst.  In  both  cases  the  hemispheres  were  punctured  in  all  directions, 
and  in  the  first  case  the  abscess  was  incised.  The  patients  complained  of  neither 
pain  nor  other  sensations.  Bloch,  Schleich,  and  Lennander  have  demonstrated  the 
insensitiveness  of  the  exposed  brain.  With  the  change  of  dressing  following  opera- 
tions on  the  brain  and  in  complicated  fractures  of  the  skull  all  surgeons  have  obser\ed 
that  the  brain  is  insensitive.  The  dura  mater,  according  to  Fiorry,  cinoting  Berefield, 
Legat,  Fontana,  and  Caldani,  is  sensitive  to  pain,  while  Chaussier,  Richerand,  and 
Fortal  (Cited  by  Bloch)  hold  the  dura  to  be  absolutely  insensitive.  At  the  present 
time  it  has  been  found  in  operations  on  the  C()n\exity  of  the  skull  that  the  dura  is 
absolutely  insensitive,  while  operations  toward  the  base  are  painful.  These  facts 
were  demonstrated  on  two  flifferent  occasions,  the  first  time  during  an  osteoplastic 
resection  of  the  skull  for  the  removal  of  a  glioma  in  the  motor  area.  Toward  the 
convexity,  the  dura  was  insensitive  as  usual,  while  toward  the  base  about  the  height 
of  the  malar  bone  the  dura  was  painful.  In  the  second  case  a  dermoid  of  the 
occipital  bone  in  the  region  of  the  occipital  tuberosity  had  perforated  both  the 
external  and  internal  table  of  the  skull  and  was  adherent  to  the  dura.  After  anes- 
thetizing the  external  nerves  it  was  possible  to  dissect  free  the  cyst  and  remove  the 
overhanging  parts  of  the  external  table  without  ])ain;  cutting  the  dura,  howe\er, 
was  very  j)ainful  notwithstanding  the  absence  of  pain  in   all  other  parts. 

Observations  as  to  the  results  just  mentioned  have  been  i)ro\ cd  in  late  years  by 
numerous  operations  on  the  skull  and  brain  carried  out  und(T  local  anesthesia.     It  has 


36  LOCAL  ANESTHESIA 

also  been  found  in  operations  on  the  cerebellum  that  the  dura  of  the  posterior  fossa 
of  the  skull,  as  well  as  the  cerebellum  itself,  is  free  from  pain  on  mo\ing,  pressing, 
crushing,  or  cutting  it. 

We  have  to  thank  Lennander  for  his  interesting  and  important  observations  on  the 
sensibility  of  the  abdomen  and  the  abdominal  organs.  The  older  statements  in  this 
regard  are  very  conflicting.  Haller  claimed  that  the  peritoneum  and  mucous  mem- 
brane of  the  intestines  were  without  sensation,  while  the  submucosa  possessed  feeling. 
In  animals  the  liver,  spleen,  and  kidneys  w^ere  found  to  be  very  slightly  sensitive. 
Piorry  claimed  the  serous  membranes  were  sensitive,  and  cites  the  experience  of 
Bichat  as  proof,  the  latter  having  seen  dogs  eat  their  own  intestines  which  had  been 
extruded  through  an  abdominal  wound.  E.  H.  Weber  held  that  prolapsed  human 
intestines  were  insensitive  to  cold  and  pressure.  Since  the  introduction  of  cocaine 
many  abdominal  operations  have  been  performed  without  general  anesthesia,  and 
surgeons  have  had  ample  opportunity  to  convince  themselves  of  the  insensitiveness 
of  the  stomach  and  intestinal  tracts,  together  with  their  peritoneal  covering.  The 
opinions  of  Flourens,  Richet,  and  Bloch  were  that  abdominal  organs  in  an  inflamed 
condition  could  become  painful.  Lennander  refuted  these  statements  in  consequence 
of  many  individual  observations,  carried  out  partly  under  local  anesthesia  on  organs 
brought  outside  of  the  body  or  sew^ed  in  the  abdominal  wall.  He  proved  conclusively 
that  the  peritoneum  of  the  anterior  and  posterior  abdominal  wall,  pelvis,  and  dia- 
phragm, the  latter  as  far  as  it  is  supplied  by  the  spinal  nerves,  were  sensitive  to  pain 
whether  in  a  normal  or  diseased  condition.  The  visceral  peritoneum  of  the  stomach, 
intestines,  omentum,  gall-bladder,  kidneys,  and  liver,  even  in  the  state  of  acute  peri- 
tonitis or  other  diseased  conditions,  does  not  possess  sensory  nerves  reacting  to  the 
usual  mechanical  and  thermic  irritation,  for  the  production  of  pain,  touch,  warmth  and 
cold.  These  parts  can,  therefore,  be  crushed,  cut  or  burned  without  producing  any 
sensation.  The  pain  elicited  from  the  parietal  peritoneum  by  the  use  of  clamps, 
cutting,  burning  or  pulling  is  very  pronounced  even  in  health,  and  as  a  rule  is  much 
increased  in  inflamed  conditions.  The  pain  can  be  localized  in  so  far  as  the  patient 
knows  whether  the  irritation  is  right  or  left  or  in  the  upper  or  lower  parts  of  the 
abdomen.  Lennander,  experimenting  on  the  mesentery,  could  not  arrive  at  positive 
results;  pulling  on  the  mesentery  produced  pain,  and  he  belicNed  that  operations  on 
the  mesentery  were  pain-free  if  pulling  was  avoided;  nevertheless  he  observed  that 
clamping  the  mesentery  of  the  appendix  with  an  artery  forceps  produced  severe  pain. 

That  the  observations  of  Lennander  are  correct,  as  far  as  they  concern  the  walls  of 
the  stomach  and  intestines,  has  been  proved  by  surgeons  in  hundreds  of  cases.  No 
matter  under  what  conditions  the  operation  is  performed,  whether  the  patient's 
abdomen  is  opened  under  "ether  narcosis"  or  the  abdominal  wall  is  made  insensi- 
tive with  cocain  or  other  anesthetics,  whether  the  operation  is  carried  out  under 


SENSATION  AND  PAIN—ANESTIIESIA   AND  ANESTHETIC  METHODS       ?>! 

<;eneral  anesthesia  or  other  secUitives,  whether  the  intestines  are  oi)erate(l  upon  after 
being  out  of  ab(h)men  for  a  long  or  short  period,  or  whether  the  stomaeh  or  in- 
testines are  sutured  through  a  small  incision  of  the  abdomen  and  immediately 
opened,  whether  this  particular  part  of  the  intestine  is  normal,  inflamed,  or 
otherwise  altered,  the  stomach  and  intestinal  walls  are  always  found  to  be 
without  sensation.  At  the  same  time  the  parietal  peritoneum  is  extremely  sensitive 
e^•erywhere,  unless  made  artificially  anesthetic.  Ritter  is  the  only  author  who  is 
supposed  to  have  seen  the  small  intestine  in  the  human  being  sensitive  to  mechanical 
and  thermic  irritation. 

Lennander  has  added  much  to  our  knowledge  regarding  the  sensibility  of  the 
mesentery.  In  a  communication  from  Bier,  he  states  that  according  to  his  observa- 
tions ligation  of  the  mesentery  is  usually  painful.  Other  observations  made  during 
an  intestinal  resection  have  also  been  described,  in  which  every  ligature  caused 
se\ere  pain.  In  many  cases  these  painful  reactions  do  not  occur,  particularly  when 
the  mesentery  is  ligated  close  to  the  intestinal  wall.  These  observations  seem  to 
point  to  the  conclusion  that  the  sensibility  of  the  mesentery  varies,  sometimes  being 
close  to  the  intestines,  and  at  other  times  farther  away  from  them.  Wilms  has  verified 
these  observations.  It  has  also  been  demonstrated  that  the  pinching  of  the  mesenterj- 
in  an  avascular  area  6  cm.  or  more  from  the  bowel  is  free  from  pain,  while  pinching 
the  vessels  2  to  3  cm.  from  the  bowel  elicits  distinct  pain.  The  close  association  of 
nerves  and  bloodvessels  in  the  mesentery  has  been  studied  in  animals  and  man  by 
Ritter  and  Propping.  It  should  also  be  noted  that  in  strangulated  hernia  the  mesen- 
tery is  without  sensation,  as  the  strangulation  not  only  can  but  must  produce  loss 
of  feeling.  It  is  a  fact  well  known  to  surgeons  that  the  clamping  of  the  mesentery 
in  the  deeper  parts  of  the  abdomen  or  the  ligating  of  the  lesser  omentum,  as  a  rule, 
causes  severe  pain  to  patients  not  under  the  influence  of  a  general  anesthetic.  No  one 
iloubts  today  that  the  mesentery  of  the  human  being  is  possessed  of  a  pronounced  sensi- 
l)ility.  The  observations  of  Wilms  and  Hesse  on  the  appendix  and  its  mesentery  are 
of  much  importance  and  coincide  with  the  experience  of  others,  viz.,  that  the  appendix 
has  no  pain  sense  but  its  mesentery  is  painful  to  manipulation.  In  ligating  or  clamp- 
ing the  mesentery  of  the  appendix  pain  is  complained  of,  not  localized  to  this  region 
but,  as  a  rule,  referred  to  the  epigastrium.  The  intensity  of  this  pain  is  quite  variable, 
at  times  so  slight  as  to  be  only  determined  by  questioning  the  patient,  at  other  times 
so  severe  as  to  require  general  anesthesia  for  its  relief.  This  same  sensation  occurs 
from  pulling  on  the  appendix  or  cecum.  The  remainder  of  the  mesentery  reacts  in 
a  similar  manner.    The  great  omentum  is  usually,  but  not  always,  insensitive. 

According  to  the  experiments  of  Kast,  IVIeltzer,  Ritter,  and  Propping  the  walls  of 
the  stomach  and  intestines  of  dogs  and  rabbits  are  sensitive  to  pain,  these  results 
being  alone  denied  by  L.  R.  Moeller.    ]\Ieltzer  and  Kast  have  made  the  observation 


38  LOCAL  ANESTHESIA 

that  in  animals  poisoned  with  cocain  not  only  is  the  skin,  cornea,  and  parietal  peri- 
tonenm  insensiti\e,  but  the  sensation  of  the  stomach  and  intestinal  tract  is  also 
lost.  It  has  been  claimed  by  these  authors  that  the  diminished  sensibility  and  absence 
of  pain  sense  in  the  intestines  of  persons  injecterl  with  cocain  for  purposes  of  local 
anesthesia  is  of  a  similar  nature,  but  Wilms,  Propping,  and  Xystroem  have  taken 
exception  to  this  theory,  as  disturbances  of  sensation  of  this  sort  are  brought  about 
only  by  toxic  doses  of  cocain.  This  appears  likewise  in  paralyses  which  are  of  central 
and  not,  as  Ritter  claims,  of  peripheral  origin.  Small  non-toxic  doses  of  cocain  (0.08 
to  0.01  per  OS  [Mosso])  do  not  cause  diminished  sensibility,  but  rather  increase  it. 
There  is,  therefore,  not  the  slightest  reason  for  doubting  observations  made  on 
persons  operated  upon  under  local  anesthesia,  as  they  coincide  with  those  made  on 
patients  operated  upon  without  cocain  or  similar  drugs  (Haim,  Mitchell,  Wilms,  and 
Propping).  Sensations  during  operation  caused  by  pulling,  clamping,  or  ligating  the 
mesentery  differ  from  other  sensations,  inasmuch  as  they  are  not  localized  and  are 
apparently  of  a  different  character.  Some  patients  do  not  speak  of  them  as  being 
painful  but  complain  more  of  uneasiness;  this  latter  feeling  can  become  so  severe 
as  to  be  unbearal)le  to  the  patient;  others  complain  of  colic-like  pain.  It  might  be 
suggested  that  we  alter  our  terminology  and  call  these  expressions  of  feeling 
abdominal  sensations. 

In  view  of  the  marked  variability  of  painful  sensations  in  races  and  individuals 
and  the  more  pronounced  character  of  abdominal  sensations  in  certain  animals,  it 
is  not  surprising  that  a  sensory  zone  of  the  mesentery  is  occasionally  found  reaching 
the  intestine  in  man.  It  is  only  surprising  that  this  observation  was  made  by  a  single 
experimenter — Ritter. 

Lennander's  experiments  prove  conclusively  that  the  cerebrospinal  nerves  can 
receive  and  transmit  painful  impressions,  while  the  sympathetic  nervous  system  can 
not.  Froehlich  and  Meyer  have  verified  these  results  beyond  dispute  by  their  impor- 
tant experiments  on  dogs.  The  disappearance  of  abdominal  sensation  following  Bier's 
lumbar  anesthesia  or  ])araverte})ral  conduction  anesthesia  (Kappes)  indicates  that 
sensation  is  transmitted  to  the  brain  through  the  spinal  cord,  independent  of  the 
vagus  nerve.  The  acti\e  discussion,  consequent  upon  the  work  of  Lennander,  regard- 
ing the  cause  of  pain  in  the  intestines  in  diseased  conditions  cannot  be  entered  into 
here. 

The  author  opened  the  gall-bladder  twice  under  local  anesthesia  and  can  verify  the 
findings  of  Lennander,  namely,  that  the  fundus  is  absolutely  insensitive  to  pressure, 
clamping,  or  cutting,  while  pulling  on  the  gall-bladder  or  sounding  the  gall  ducts  is 
l)ainful;  this  latter  can  be  demonstrated  in  all  fistulse  of  the  gall-bladder.  Accord- 
ing to  Ritter  the  ligation  of  the  cystic  artery  and  tying  off  of  the  gall-bladder  are 
painful. 


SKXSATIOX   AM)   I'M  X—A  XESTIIESIA    AXI)   AXKSTIIETIC   METHODS       \\\) 

That  the  livor  is  without  pain  sense  has  loni^-  been  known  to  sursi-eons.  The  openin.u' 
of  an  ecehinoeoeeus  cyst  of  the  Ii\-er,  sutured  to  the  ahdoiiiinal  wall,  recjuires  no 
more  anesthetie  than  the  openint;-  of  a  l()t)p  of  intestine  fixed  in  like  manner.  In  the 
opening  of  a  liver  abscess  in  two  stages  the  convex  surface  of  the  right  lobe,  as  well 
as  the  li\er  parenchyma  absolutely  was  found  insensitive  to  pain  and  movement. 

Lt'unander  found  the  kidney,  exposed  by  operation,  to  be  insensitive  to  operati\e 
])ro(edures  as  well  as  to  heat  and  cold.  It  might  l)e  added  that  the  kidney  was  freed 
of  its  fatty  capsule.  Bloch  l)elieves  that  the  kidney  has  very  little  sensation,  while 
Schleich  contends  that  the  kidney  parenchyma  is  practically  free  from  pain  sense. 

In  regard  to  the  uterus,  Lennander  found  the  surface  of  the  fundus  insensitive  to 
the  thermocautery,  likewise  the  ovary  and  tube.  He  cited  a  communication  from 
Viet  in  which  the  latter  had  repeatedly  performed  Cesarean  section  without  anes- 
thesia, of  course  not  tying  off  the  uterus  or  removing  it  from  the  abdomen.  Reclus 
and  Schleich  state  that  in  extirpation  of  ovarian  tumors  anesthesia  of  the  pedicle 
is  necessary.  In  three  cases  of  ovarian  cystoma  which  were  removed  under  local 
anesthesia  the  ligation  and  cutting  of  the  pedicle  was  without  pain;  the  pedicle  was 
not  anesthetized.  The  portio  vaginalis  is  not  sensitive  to  pain,  but  the  pulling 
down  of  the  uterus  during  operation  is  painful.  The  peritoneum  of  the  fundus 
of  the  bladder  was  found  by  Lennander  to  be  insensitive. 

Investigations  regarding  sensation  in  the  testicle  and  epididymis  are  so  incomplete 
that  there  is  very  little  to  be  said  at  this  time.  This  much  is  certain,  that  in 
operations  on  the  testicle,  complete  anesthesia  of  the  organ  and  its  co^•erings 
is  necessary. 

The  parietal  pleura  acts  just  as  the  parietal  peritoneum,  and  is  very  sensitive  to 
])ain.  This  can  be  noted  in  every  exploratory  puncture.  At  the  moment  of  punctur- 
ing the  pleura  the  patient  complains  of  pain.  This  is  equally  true  in  thoracotomy 
if  the  anesthesia  has  been  incomplete.  This  observation  has  also  been  ^'erif^ed  by 
Lennander,  The  pulmonary  pleura  is  insensitive.  Garre,  in  describing  the  technique 
of  lung  operations,  says:  "In  operating  in  two  stages,  pneumotomy  can  be  per- 
formed in  the  second  stage  without  general  or  local  anesthesia;  the  lung  tissue  is 
absolutely  insensitive."  It  is  generally  recognized  that  pleurisy  is  painful,  while 
central  pneumonia  and  chronic  inflammation  of  the  lungs  unaccompanied  by 
])leurisy  is  ])ainless.  Lennander  has  also  positi\-ely  determined  that  the  thyroid 
gland  is  absolutely  insensitive  to  mechanical,  chemical,  or  thermic  stimuli. 

The  sense  of  pain,  as  we  see,  is  a  property  of  the  tissues  wadely  distributed  through- 
out the  body.  It  is  often  present  where  the  other  senses  or  ordinary  sensation  is 
absent.  Under  the  circumstances  it  is  very  probable  that  pain  sense  has  special 
nerves  with  specific  end  organs  for  its  transmission.  From  a  practical  point  of 
view  local  anesthesia  will  <)nl\-  have  a  future  and   be  able  to  compete  with  general 


40  LOCAL  ANESTHESIA 

anesthesia  if  all  the  tissues  in  the  operative  field  having  cerebrospinal  nerves  can 
be  made  insensitive.  The  only  tissues  not  requiring  anesthesia  are  those  of  the 
brain,  abdominal  organs,  and  lungs. 

By  anesthesia  we  understand  the  complete  loss  of  sensation;  analgesia  signifies 
only  the  absence  of  pain.  Anesthesia  can  be  produced  by  a  break  in  the  centripetal 
conducting  sensory  nerves,  by  a  paralysis  of  function  in  the  central  end  organ  in  the 
brain,  or  by  a  paralysis  of  the  peripheral  end  organs  in  the  tissues.  If  paralysis  affects 
the  function  of  the  centres  in  the  brain,  we  speak  of  a  central  anesthesia;  this  extends 
over  the  entire  body  and  is  usually  associated  with  a  disturbance  of  consciousness. 
The  latter  is  intentionally  attempted  in  general  anesthesia  for  surgical  purposes,  very 
seldom  in  hypnosis. 

Paralysis  of  the  peripheral  sensory  nerve  organs  brings  about  a  condition  which 
in  the  terminology  of  the  physiologist  is  called  peripheral  or  terminal  anesthesia. 
It  is  exactly  confined  to  those  tissues  in  which  the  function  of  the  end  organ  is  in- 
hibited. If  the  conductivity  of  a  sensory  nerve  is  interrupted  at  any  point  between 
the  brain  and  periphery,  all  the  tissues  supplied  by  this  nerve  alone  will  become 
anesthetic.     This  is  termed  conduction  anesthesia. 

Terminal  and  conduction  anesthesia  when  used  in  eliminating  pain  in  surgery 
are  classed  together  under  the  terms  local  anesthesia  or  local  analgesia.  Inasmuch 
as  our  methods  of  local  anesthesia  produce  a  paralysis  of  all  sensation  just  as  often 
as  a  paralysis  of  pain  sense,  without  interfering  with  the  special  senses  such  as  touch 
etc.,  there  is  no  reason  for  abandoning  the  old  and  now  universally  used  term  of 
local  anesthesia. 

The  remedies  at  our  disposal  for  the  production  of  local  anesthesia  are  partly 
physiological,  and  partly  chemical  in  their  action.  Severe  pressure  on  a  nerve  trunk 
renders  it  incapable  of  conduction.  Severe  or  long-continued  cooling,  causing  either 
a  swelling  or  owing  to  the  loss  of  water  a  shrinking  of  nerve  elements,  will  cause  a 
temporary  loss  of  function.  This  same  thing  occurs  when  certain  drugs,  local  anes- 
thetics, are  brought  in  contact  with  nervous  elements.  The  object  of  the  following 
chapter  will  be  to  give  the  theory  and  practice  of  anesthesia  from  pressure,  together 
with  the  history  not  already  mentioned. 


CHAPTER   III. 

THE   PAIX-RELIEVING   ACTION   OE  NERVE   COMPRESSION  AND 
ANEMIA. 

jNIechanical  pressure  on  a  nerve  trunk  can  cause  a  break  in  conduction,  with 
consequent  motor  and  sensory  paralysis  in  the  tissues  suppHed  by  it  (conduction 
anesthesia).  Dailj'  observations  in  the  living,  such  as  the  going  to  sleep  of  a  limb, 
radial  paralysis  from  pressure  on  a  nerve  trunk,  experience  gained  in  ligating  a  limb 
during  amputations  for  purposes  of  checking  hemorrhage,  caused  the  physicians  of 
former  times  to  utilize  this  measure  for  purposes  of  local  anesthesia.  We  have 
already  followed  this  history  up  to  the  time  Esmarch  used  the  elastic  tube  or  bandage 
for  purposes  of  blood-letting  or  hemostasis,  at  which  time  it  became  a  part  of  surgical 
technique.  ]\Iany  investigators  at  this  time  studied  the  physiological  action  of  the 
anemia  in  limbs  thus  ligated,  and  the  majority  believed  that  both  sensation  and  motion 
were  affected.  The  actual  results  of  these  experiments  in  animals,  and  in  healthy  or 
diseased  persons,  seem  to  the  majority  of  observers  (Nicaise,  Verneuil,  Billroth, 
Fischer,  Bruns,  Chauvel,  Riedinger,  Kappeler,  Karewski)  to  produce  various  forms 
of  paresthesias  in  the  ligated  limb  but  little  or  no  diminution  to  sensations  of  pain. 
Some  few  experimenters  (Neuber,  Iverson,  Le  Fort,  Stockes),  after  ligating  an  arm 
or  leg,  found  a  fairly  extensive  anesthesia  following,  beginning  in  the  fingers  or  toes 
and  gradually  extending  to  a  greater  or  less  degree  over  the  entire  extremity.  Inas- 
much as  they  all  rendered  the  limb  on  which  they  were  experimenting  bloodless,  to 
the  point  of  interrupting  the  blood-supply,  it  seems  that  the  prevailing  opinion  as 
to  the  anemia  of  the  tissues  causing  disturbance  of  sensation  was  not  very  probable. 
The  old  surgeons,  Juvet,  Thedon,  Liegard  (see  Chapter  I)  were  never  of  any  other 
opinion  than  that  the  pressure  on  the  nerve  trunks  caused  by  ligating  a  limb  pro- 
duced conduction  anesthesia  in  the  peripheral  parts.  If  attempts  are  made  to  control 
these  experiments  in  such  a  way  as  not  only  to  interrupt  the  blood-supply  but  also  to 
exercise  a  certain  measured  pressure  on  the  nerve  trunks,  the  following  will  be  noted : 
Peripheral  ligation-anesthesia,  as  already  noted  by  Krieshaber,  Verneuil,  etc.,  only 
occurs  when  the  pressure  of  the  constricting  rubber  tube  far  surpasses  the  pressure 
necessary  to  interrupt  the  blood-supply.  Very  strong  ligation  is  necessary  in  order 
to  produce  a  diminution  of  sensation  in  a  reasonable  length  of  time,  and  then  this  is 
usuallv  confined  to  a  hand  or  foot.     The  intensitv  and  extent  of  liijation  anesthesia 


42  LOCAL  ANESTHESIA 

will  be  in  direct  proportion  to  the  degree  of  pressure  on  the  nerve  trunks.  The  more 
widely  distributed  the  peripheral  sensory  disturbance,  the  greater  the  subjective 
pain  at  the  point  of  ligation,  the  pain  being  often  unbearable.  The  degree  of  pressure 
on  a  nerve  is  not  only  dependent  upon  the  tightness  of  the  ligature  but  also  on  the 
condition  of  the  limb,  the  nature  of  the  ligature,  and  the  place  of  ligation.  In  the 
upper  arm  of  a  thin  woman  or  child  a  carefully  placed  rubber  band  readily  interrupts 
the  bloofl-stream  without  causing  peripheral  sensory  disturbance  or  subjective  pain 
of  any  consequence.  In  muscular  limbs  this  is  not  sufficient,  and  strong  pressure  is 
necessary  for  the  interruption  of  the  blood-stream  which  at  the  same  time  interferes 
with  nerve  conduction.  A  wide  rubber  band  naturally  causes  less  pressure  than  a 
narrow  one  placed  on  a  circumscribed  area.  A  rubber  tube  wrapped  tightly  about 
a  thin  upper  arm,  rapidly  produces  muscular  and  sensory  paralysis,  and  as  is  well 
known  the  motor  paralysis  may  be  persistent.  ]\Iotor  and  sensory  paralysis  occurs 
quickly  in  the  area  supplied  by  the  radial  ner\'e  if  a  rubber  tube  is  wrapped  about 
the  upper  arm  where  the  nerve  trunk  lies  to  the  outer  side  and  unprotected 
by  muscle.  For  the  reasons  just  mentioned  the  degree  of  pressure  for  the  nerve 
trunks  is  difficult  to  estimate  and  easily  explains  the  difference  in  the  obser^'ations 
of  the  before-mentioned  authorities. 

The  fingers  are  much  more  suitable  for  these  experiments  than  the  larger  sections 
of  the  limbs,  as  the  finger  base  is  readily  compressed,  light  pressure  being  sufficient 
to  control  the  blood-stream,  thus  producing  constant  experimental  conditions  so  that 
the  questionable  factor  of  the  degree  of  pressure  can  be  eliminated.  The  fingers 
will  stand  a  severe  degree  of  constriction  for  a  considerable  length  of  time  without 
danger.  For  these  experiments  a  number  of  rubber  bands  are  necessary,  ^  arying 
in  thickness  and  strength.  The  bands  which  we  will  term  No.  1  will  stop  the  circu- 
lation with  the  least  possible  pressure,  as  judged  by  the  color  of  the  fingers,  the  bands 
Xo.  2  exert  medium  pressure  and  those  designated  as  No.  3  strong  pressure.  All 
these  bands  are  applied  by  rolling  them  along  the  finger  from  tip  to  base. 

The  results  of  these  experiments  can  be  explained  in  a  few  words.  Bands  of  weak 
and  medium  strength  are  left  in  place  two  hours.  With  bands  Xo.  1,  besides  par- 
esthesia and  numbness,  only  a  diminution  of  the  sense  of  touch  in  the  phalanx  is 
noted.  With  bands  X'^o.  2,  loss  of  the  same  sense  of  touch  is  present,  which,  begin- 
ning in  the  end  phalanx  gradually  extends  to  the  middle  phalanx.  The  feeling  of  a 
needle-prick  is  i)r()bably  increased  after  two  hours;  at  any  rate  it  is  not  diminished. 
Bands  X'o.  3,  exerting  strong  pressure  after  half  to  one  hour,  besides  the  previously 
mentioned  sensations,  cause  a  distinct  diminution  of  the  sense  of  pain  in  the  terminal 
phalanx  which  occasionally  extends  to  the  middle  phalanx.  Severe  sensory  dis- 
turbance is  present  during  the  time  of  ligation.  On  releasing  the  ligature,  sharp, 
shooting   pains   of   short   duration   occur  in    the  finger.      Although  disturbance  of 


THE  PAIX-RELIEVIXa  ACTIOX  OE   XERVE  COM I'h'ESSlOX   A  XI)  AXEM/A      43 

sensation  l)cpns  in  the  finder  tips  and  extends  toward  their  l)ase.  and  the  extent  and 
intensity  of  this  anesthesia  is  in  (Hrect  i)rop()rti()n  to  the  pressnre,  still  the  anemia 
of  the  tissues  remains  the  same. 

Aeeordin"-  to  more  reeent  investigations  by  Boeri  and  SiKester,  j)ain  sense  of  all 
the  senses  is  the  most  resistant  to  pressure  on  the  nerve  trunks  and  disa})pears  last. 
The  first  senses  to  disappear  are  those  of  touch  and  pressure,  temperature  sense 
occupying  an  intermediate  position. 

The  author  observed  complete  anesthesia  of  the  finger  but  once  sufficient  for  oi)era- 
x'wv  work.  In  this  case  the  base  of  the  middle  finger  was  bound  very  tight  with  several 
turns  of  a  very  thin  rubber  band.  In  about  fifteen  minutes  the  finger  was  perfectly 
insensitive,  and  remained  so  after  the  removal  of  the  band,  and  not  until  several  months 
later  did  normal  sensation  gradually  return.  There  were  no  disturbances  of  circulation 
at  the  site  of  ligation,  the  condition  being  due  to  a  pure  nerve  lesion,  a  nerve  crushing, 
as  it  were,  with  its  usual  consequences.  After  tight  ligation  of  an  arm  or  leg  a  per- 
sistent motor  paralysis  is  more  likely  to  result  than  a  sensory  paralysis.  According 
to  the  experiments  of  Luederitz  the  motor  nerves  are  more  easily  paralyzed  and 
injured  by  pressure  of  a  band  than  the  sensory  ne^^•es;  at  the  same  time  the  sensory 
nerves  recover  sooner  than  motor  nerves  from  pressure  paralysis.  These  observa- 
tions coincide  exactly  with  clinical  experience  (anesthesia  paralysis  and  compression 
myelitis). 

We  must  conclude  from  these  observations  and  experiments  that  the  surgeons  of 
old  were  perfectly  right  in  attributing  ligation  anesthesia  to  pressure  on  the  nerves. 
The  anemia  accompanying  ligation,  with  its  consequent  disturbance  of  nutrition,  is 
only  of  secondary  importance,  as  a  diminution  or  loss  of  sensation  from  this  cause 
occurs  quite  late,  as  can  be  observed  in  tightly  ligating  a  limb.  A  finger  rendered 
anemic  requires  considerable  time  before  a  benumbed  or  painless  condition  ensues. 

The  reaction  of  nerve  tissue  to  diminished  or  interrupted  circulation  is  not  uniform. 
The  brain,  medulla  and  spinal  cord  of  warm-blooded  animals  is  very  sensiti\e  to 
Huetuations  of  blood-pressure,  while  the  peripheral  nerve  trunks,  on  the  contrary,  are 
independent  of  the  oxygen  supply  to  a  great  extent  (Ranke  and  Ewald)  and  retain 
the  power  of  transmission  hours  after  the  cessation  of  the  blood-supply  (Schift'er). 
The  end  organs  of  sensory  and  motor  nerves,  exclusive  of  the  retina,  occupy  a  middle 
j)osition  between  these  extremes.  Schiff'er's  experiments  on  warm-blooded  animals 
demonstrated  that  it  requires  about  one  hour  after  the  cutting  off  of  the  blood-supply 
for  loss  of  function  to  occur.  In  apparent  contradiction  to  this  is  the  so-called  Stenson 
experiment  (the  high  ligation  of  the  abdominal  aorta)  of  the  physiologists,  in  which 
an  immediate  sensory  and  motor  paralysis  occurs  in  the  lower  extremities.  Schiffer 
and  Weil  have  shown  that  this  sudden  paralysis  was  due  to  the  simultaneous  complete 
anemia  of  the  lower  segment  of  the  cord,  and  did  not  occur  if  the  aorta  were  ligated 


44  LOCAL  ANESTHESIA 

lower  down  just  above  the  point  of  its  division,  thus  limiting  the  ischemia  to  the  lower 
extremities.  It  was  possible  for  Ehrlich  and  Brieger,  in  carrying  out  the  Stenson 
experiment  on  rabbits,  in  those  that  lived  long  enough,  to  demonstrate  that  the 
largest  part  of  a  cross  section  of  the  gray  matter  of  the  cord  in  its  lower  segment 
was  destroyed  as  well  as  the  more  important  motor  areas  in  the  white  substance. 
Singer  and  Spronck  later  studied  in  histological  detail  the  cause  and  course  of  this 
anemia-necrosis. 

This  question  will  probably  require  further  investigation,  consequent  upon  the 
recent  animal  experiments  of  Katzenstein  and  the  cases  of  Schlesinger,  in  which  the 
latter  saw  ischemic  sensory  paralysis  of  the  lower  extremities  occur  a  few  minutes 
after  the  sudden  blocking  of  their  bloodvessels  by  embolism.  The  work  of  Schiff 
again  disproves  these  observations;  however,  no  matter  what  the  outcome  of  this 
controversy  may  be,  the  fact  remains  that  ligation  anesthesia  is  due  to  pressure 
on  the  nerve  trunks. 

Ligation  anesthesia  is  used  just  as  seldom  today  in  operations  on  the  low^er  extrem- 
ities as  in  former  centuries.  Esmarch,  in  his  description  of  artificial  anemias,  says 
that  he  uses  this  procedure  in  all  small  surgical  operations  on  fingers  and  toes,  such 
as  incision  for  felons,  removal  of  ingrown  nails,  exarticulation  of  phalanges,  etc. 
Stockes  and  Le  Fort  describe  major  operations  as  the  extirpation  of  a  carcinoma  from 
the  back  of  the  hand,  resection  of  the  elbow-joint,  amputation  of  the  leg,  performed 
in  this  way  without  pain.  Again,  in  recent  times  Kofmann  has  advocated  ligation 
for  the  production  of  anesthesia  of  the  extremities,  but  this  in  all  probability  will  not 
restore  this  measure  to  use  again.  The  effect  is  too  uncertain  and  the  evil  conse- 
quences too  great.  The  necessary  pressure  on  the  nerve  trunks  must  be  so  severe, 
and  the  pressure  dosage  so  uncertain  that  the  danger  of  gangrene,  permanent  motor 
and  sensory  paralyses  are  avoided  with  difficulty.  Kofmann  experienced  his  first 
serious  consequence  of  this  method  on  himself.  It  should  once  again  be  emphasized 
that  long-continued  ligation  of  an  extremity  is  extremely  painful  even  for  those  not 
necessarily  sensitive.  For  these  reasons  compression  anesthesia  was  given  up,  even 
in  those  times  when  better  and  more  certain  methods  of  general  anesthesia  were 
unknown. 


CHAPTER   IV. 


ANESTHESIA   BY  IMP^ANS  OE  COLD. 


Of  much  practical  importance  is  the  paralysis  of  nerve  function  by  means  of  low 
temperatures.  Although  long  known  (see  Chapter  I),  Arnott  (1848)  was  the  first 
to  use  this  method  in  surgery  to  any  extent.  Eor  the  rapid  chilling  of  the  tissues  he 
used  rubber  bags  and  pigs'  bladders  filled  with  a  mixture  of  ice  and  salt  and  laid  them 
upon  the  skin  in  the  field  of  operation.  He  made  the  following  observations:  anes- 
thesia of  the  tissues  produced  by  cooling  was  confined  to  the  outer  sensitive  parts, 
and  inasmuch  as  the  most  painful  part  of  many  operations  was  located  in  these  tissues, 
the  application  of  cold  was  sufficient  even  if  the  patient  experienced  some  pain,  and 
was  to  be  preferred  to  chloroform  and  ether  which  caused  loss  of  consciousness. 
The  application  of  cold  in  this  form  is  free  from  injury  and  danger  to  the  tissues. 
According  to  Velpeau,  Arnott's  method  of  chilling  the  skin  suffices  for  all  superficial 
operations.  Num,  Herzog,  Illig,  Wittmeyer, 
and  others  heartily  recommend  this  measure, 
and  Galeczowski  used  this  method  in  lid  opera- 
tions. Ice  and  salt  mixtures  were  soon  dis- 
carded for  the  simpler  method  of  using  rapidly 
e\aporating  fluids. 

Demarquay,Guerard,  ]{ichet,  and  others  used 
sulphuric  ether,  by  dropping  it  on  the  skin  in 
the  field  of  operation  and  later  constructed  a 
blower  for  causing  the  ether  to  evaporate  on 
the  surface  to  which  it  was  applied,  and  by 
this  means  found  that  the  skin  could  be  ren- 
dered insensitive.  Ricket's  experience  (1854) 
showed  that  much  progress  had  been  made, 
for  until  this  time  local  anesthesia  never  gave 
uniformly  good  results.  The  first  real  impetus 
to  the  use  of  cold  as  an  anesthetic  came  when  Richardson,  in  18G6,  devised  the 
atomizer,  suggested  to  him  by  Giraldes,  for  the  purpose  of  using  ether  and  chlo- 
roform in  a  finely  divided  spray  on  the  skin.  Richardson's  ether  spray  (Eig.  1) 
consisted  of  a  finely  pointed  metal  tube  through  which  a  strong  stream  of  air  could 


46  LOCAL  ANESTHESIA 

be  blown  by  means  of  a  double  rubber  bulb,  this  mixed  with  the  ether  sucked 
through  another  metal  tube  from  a  glass  container.  By  this  means  ether  was  finely 
subdivided  and  in  condition  to  be  rapidly  evaporated,  producing  intense  cold.  For 
the  extraction  of  teeth  a  fork-shaped  end-piece  with  two  openings  was  used.  Under 
the  influence  of  the  ether  spray  the  temperature  rai)i(lly  dropped  to  —15°  or  —20°  C, 
sufficient  to  quickly  turn  a  test-tube  of  water  into  ice. 

If  the  ether  spray  is  used  at  a  distance  of  about  5  cm.  from  the  skin  the  latter  be- 
comes reddened,  and  in  a  few  minutes  white,  hard,  and  insensitive;  in  fact,  the  skin 
is  frozen.  Sometimes  the  white  and  hard  appearance  of  the  skin  does  not  occur, 
yet  the  parts  are  insensitive;  but  these  parts  are  irritated  mechanically  by  rubbing 
the  back  of  a  scalpel  over  the  surface,  or  by  pricking  it  with  the  point  of  the  knife, 
the  tissues  change  their  color  and  consistency  immediately  and  present  the  usual 
frozen  appearance.  All  grades  of  ether  can  be  used  for  this  purpose.  The  best  to 
obtain  sufficient  heat  dissipation,  is  pure  water-free  sulphuric  ether  having  a 
specific  gravity  of  0.720  and  a  boiling-point  of  34.5°  (\;  this  is  the  so-called  anesthetic 
ether  of  commerce.  Sensiti\-e  tissues,  as  the  skin  of  the  scrotum,  must  be  protected 
from  the  direct  ether  spray  by  coating  the  parts  with  vaseline  or  glycerine,  or  by  inter- 
posing a  metal  plate  (ProsorofF)  between  spray  and  skin.  To  p^e^'ent  the  unevap- 
orated  ether  running  over  the  skin,  Lesser  constructed  metal  boxes  to  fit  various 
parts  of  the  body.  These  boxes  were  filled  three-quarters  full  of  ether  and  by  blowing 
a  stream  of  air  rapidly  through  them,  evaporation  quickly  occurred;  the  box  was  then 
pressed  against  the  skin  until  frozen.  Braatz  constructed  an  apparatus  along  these 
same  lines,  which  was  used  particularly  for  making  very  small  areas  of  skin  or  mucous- 
membrane  insensiti^•e  for  the  purpose  of  injecting  anesthetic  fluids.  These  contriv- 
ances were  unnecessary  and  never  came  into  general  use.  The  action  of  ether  on  the 
tissues  is  more  intense,  lasting  and  acting  better  on  the  deeper  lying  parts,  if  the 
extremity  is  first  ligated  to  prevent  the  access  of  fresh  warm  blood  (Girard,  1874). 
The  freezing  of  the  tissues  occurs  very  quickly  by  this  method,  and  the  thawing  and 
return  of  sensation  is  very  slow.  Instead  of  ether,  various  other  hydrocarbons  can 
be  used  in  the  Richardson  apparatus,  only  the  more  important  of  which  can  be 
mentioned  here.  P^thyl  bromide  (boiling-point  +38°,  Terrilon,  IMonad,  Perrier,  and 
Berger),  carbon  disulphide  (boiling-point  +48°,  Simonin,  Delcominette,  Claude 
Bernard),  petroleum  ether  (boiling-point  +38°,  Bigelow^  Warren),  chloroform 
(boiling-point  +(;i°),  ethylene  chloride  (licpior  hollandicus,  boiling-point  +58°), 
amylene  (boiling-point  +3)5°),  Bobbins'  anesthetic  ether  (a  mixture  of  methyl 
alcohol  and  chloroform).  The  local  anesthetic  property  of  all  these  preparations  is  in 
inverse  proportion  to  their  boiling-point  (Rosenthal,  Bumm),  the  action  being  brought 
about  by  dissipation  of  heat  due  to  rapid  evaporation.  Anesthesia  must  not  be  attrib- 
uted to  chemical  or  narcotic  action  on  the  sensory  nerves  at  the  point  of  application, 


\ 

i 

J 


AXK^TIIESIA   JiV   MEAXS  OF  (OLD  47 

as  was  supposed  to  be  the  case  by  early  investigators.  The  only  agent  of  those  men- 
tioned having  advantages  over  ether  is  ethyl  bromide,  as  it  is  not  inflammable. 

The  experimental  work  of  Gruetzner,  Gendre,  Heinzmann,  and  l^'ratschcr  takes 
lip  the  physiological  effect  of  cold  on  the  nerve  substance  in  animals. 

Slightly  cooled  nerves  retain  their  property  of  reacting  to  stimulation  for  consid- 
erable time;  cooling  to  +5°  C.  inhibits  the  stimulation  of  all  nerve  fibers  cooling 
t(^  the  point  of  ice  formation  intercepts  nerve  function,  the  nerve,  however,  regaining 
its  proi)erty  of  reacting  to  irritation  on  thawing.  Sudden  intense  cold  acts  as  a  stim- 
ulus; slow  cooling  even  to  —4°  to  —  ()°  does  not  stimulate.  It  is  undoubtedly  the 
cooling  alone  which  brings  about  the  molecular  change  and  injury  to  nerves,  which 
require  a  normal  temperature  for  normal  action.  The  effect  of  jjrolonged  low  tem- 
perature on  the  human  skin  is  first  to  cause  a  contraction  of  the  smooth  muscle  fibers 
of  the  skin  and  vessels.  This  is  followed  later  by  paralysis  in  them;  the  skin  seems, 
therefore,  at  first  pale,  later  livid.  The  circulation  in  the  vessels  of  the  skin  is  finally 
stopped,  and  partly  from  this,  and  partly  from  the  direct  action  of  the  cold  on  living 
protoplasm,  certain  functions  are  rapidly  destroyed,  tlie  tissues  become  insensitive, 
necrotic  or  gangrenous,  or  serious  disorders  of  circulation  remain.  These  changes 
have  been  observed  with  temperatures  above  (J°  ('.,  but  require  a  much  longer  time 
for  action.  The  various  senses  of  the  skin  do  not  react  uniformly  to  cold.  According 
to  Boeri  and  Silvestro  the  sense  of  pressure  remains  intact  a  long  time  in  the 
presence  of  cold;  the  sense  of  touch  is  less  resistant  than  the  temperature 
sense.  The  sense  of  pain  is  lost  more  quickly  and  completely  than  any  of  the 
other  senses. 

For  the  practical  application  of  cold  in  local  anesthesia  very  low  temperatures  are 
necessary  for  the  rapid  cooling  of  the  tissues  to  the  freezing-point  (  —  0.55°  to  —0.56°). 
The  length  of  time  necessary  to  freeze  the  tissues  depends  not  only  on  the  rapidity 
of  heat  dissipation,  but  also  upon  the  nature  of  the  tissues,  that  is,  the  amount  of 
blood  in  them,  the  rapidity  of  the  blood-current,  etc.;  hyperemic  tissues  being  cooled 
much  more  slowly  than  anemic  ones.  Sensory  nerves  lose  their  function  as  soon 
as  the  tissues  are  cooled  below  the  freezing-point.  There  is  a  paralysis  of  the  sensory 
nerve  organs  that  is  a  terminal  anesthesia,  and  the  degree  of  anesthesia  depends  upon 
the  duration  of  the  freezing  process.  In  rapidly  cooling  the  tissues,  anesthesia  is 
preceded  by  pain;  with  the  thawing  of  the  tissues  sensation  rapidly  returns,  provided 
there  has  not  been  permanent  damage  to  the  parts  in  consequence  of  se\ere  freezing 
long  continued.  In  this  case  the  insensitive  area  is  converted  into  one  of  marked 
hyperesthesia,  which  is  due  solely  to  the  freezing.  As  previously  described  in  connec- 
tion with  the  ether  spray,  namely,  that  the  already  reddened  skin  with  continued 
cooling  suddenly  becomes  bloodless  and  white,  and  that  this  can  readily  be  brought 
about  if  the  reddened  area  is  scratched  witli  an  instrument,  is  explained  in  a  very  weak 


48 


LOCAL  ANESTHESIA 


and  unsatisfactory  way  by  Letamendi.  He  believes  that  anesthesia  is  brought  about 
by  a  severe  cramp  of  the  vasomotor  nerves.  For  this  to  occur  the  dilated  capillaries 
must  undergo  contraction.  This  is  rarely  brought  about  by  the  ether  spray,  while 
a  slight  emptying  of  the  hyperemic  vessels,  or  an  increase  in  tension  of  the 
vasomotor  nerves  which  is  produced  by  a  superficial  irritation,  rapidly  brings 
about  the  vessel  cramp.  Regarding  this  theory  it  is  sufficient  to  say  that  a  sudden 
contraction  of  the  bloodvessels,  with  its  consequent  anemia,  never  immediately 
interrupts  sensory  impulses;  moreover,  loss  of  sensation  often  precedes  the  white 
appearance  of  the  skin.  The  sudden  hardening  and  white  appearance  of  the  skin  can 
be  more  readily  explained  on  a  physical  basis,  these  changes  being  due  to  the  forma- 
tion of  ice  in  the  tissues.  The  delay  or  non-appearance  of  this  condition,  as  well  as 
its  sudden  occurrence  following  mechanical  irritation  in  tissues  cooled  below  the 
freezing-point,  is  due  to  delay  in  crystallization.  In  determining  the  freezing-point 
of  liquids,  we  find  that  albuminous  fluids,  such  as  blood,  require  cooling  far  below 
that  of  pure  water  before  ice  formation  begins. 

With  the  use  of  the  newer  agents  for  producing  anesthesia  by  means  of  cold,  the 
Richardson  spray  has  been  almost  entirely 
superseded  by  sprays  of  more  rapid  action, 
these  freezing  the  tissues  very  quickly  without 
any  other  aid.  The  chemicals  which  are  now 
being  used  have  a  much  lower  boiling-point 
than  ether,  producing  intense  cold  on  evapo- 
ration ;  for  this  purpose,  ethyl  chloride,  methyl 
chloride,  and  liquid  carbonic  acid  gas  are  the 
most  useful.  These  agents  at  the  ordinary 
room  temperature  and  under  normal  atmo- 
spheric pressure  change  to  gas,  so  that  they 
must  be  kept  in  containers  under  pressure. 

Ethyl  chloride  (Kelen)  C2H5CI  is  a  color- 
less gas  which  at  a  temperature  of  +11°  C, 
is  converted  into  a  colorless  liquid.     Pure  or 
mixed   with  sulphuric  ether,    Rottenstein   in 
1867  used  it  for  purposes  of  local  anesthesia, 
but  it  was  only  through  the  efforts  of  Redard, 
Baudouin,  Ehrmann,  Gans,  and  von  Hacker 
that  ethyl  chloride  became  extensively  used  in 
surgery  and  dentistry.    This  agent  was  formerly  made  only  in  France  and  Switzer- 
land, but  is  now  produced  in  almost  all  countries,  the  quality  being  equal  to  the 
imported  article  and  the  price  more  reasonable.       It  is    handled  in  the  shops  in 


Fig.  2. — Ethyl  chloride  tubes. 


i 


ANESTHESIA   BY  MEANS  OF  COLD 


49 


the  form  of  either  metal  containers  or  glass  tubes,  sealed  or  having  metallic  closing 
devices,  the  quantity  varying  from  10  to  100  c.c.  The  most  convenient  package 
is  the  glass  tube  with  a  metallic  screw  top,  having  a  capillary  opening  at  one  end 
or  at  right  angles  to  the  tube.  The  tubes  are  opened  by  unscrewing  the  cap  or 
lireaking  the  capillary  tube.  Another  convenient  container  is  on  the  market 
w  ith  an  opening  closed  by  a  cap  operated  by  finger  pressure.  The  warmth  of  the 
hand  is  sufficient  for  vaporizing  the  fluid  which  is  forced  out  in  a  strong  stream. 
The  evaporation  of  ethyl  chloride  produces  a  temperature  of  —35°  C.  and  causes 
immediate  freezing  of  the  skin  if  held  betw^een  30  to  40  cm.  from  the  surface.  The 
freezing  is  much  facilitated  by  blowing  on  the  liquid,  thus  aiding  its  evaporation.  The 
so-called  Kuehnen's  fork  spray  is  a  valuable  addition  to  the  ethyl  chloride  container 
for  use  in  the  extraction  of  teeth.  This  apparatus  permits  a  constant  stream  of  air 
to  pass  through  the  two  openings  through  which  ethyl  chloride  is  passing,  thus 
causing  rapid  evaporation,  both  sides  of  the  tooth  and  gums  being  sprayed  at 
the  same  time.     For  the  method  of  application  see  Chapter  XL 


Fig.  3. — Kuehnen's  forked  freezing  appar;itns. 


Methyl  chloride,  CH3CI,  under  high  pressure,  is  a  clear  liquid  which  boils  at  a 
temperature  of  —23°  C,  for  which  reason  it  must  be  kept  in  metal  cylinders.  Lallier 
and  Debove  were  the  first  to  use  this  agent  for  local  anesthesia.  They  allowed  the 
stream  of  liquid  to  play  upon  the  skin  direct  from  the  container,  producing  a  tem- 
perature of  —55°.  This  very  low  temperature  could  easily  cause  injury  to  the  skin, 
as  blistering,  or  even  gangrene. 

It  seems  safer  and  more  practical,  if  one  desires  to  apply  this  liquid,  to  use  Bailly's 
indirect  method.  Tampons  varying  in  size  and  form,  consisting  of  cotton  on  the  inside, 
4 


50  LOCAL  ANESTHESIA 

the  exterior  of  floss  silk,  and  a  single  layer  of  silk  gauze,  are  saturated  in  methyl 
chloride  either  by  playing  a  stream  of  methyl  chloride  upon  them  or  dipping  them 
into  the  fluid,  which  may  be  kept  nearly  three  hours  in  the  thermoisolator  constructed 
by  Bailly.  This  apparatus  consists  of  a  glass  tube  15  cm.  in  length,  placed  vertically 
in  a  glass  vessel  resting  upon  a  wooden  support.  The  circular  space  between  the 
upper  edge  of  the  tube  and  the  outer  glass  vessel  is  hermetically  sealed  and  the  air 
between  the  tube  and  the  surrounding  glass  vessel  is  exhausted.  The  whole  apparatus 
is  then  isolated  by  a  poor  conductor  of  heat  and  the  inner  tube  containing  the  methyl 
chloride  closed  with  a  cork  containing  a  capillary  glass  tube  in  order  to  allow  the 
escape  of  the  volatilized  fluid.  The  tampons  are  held  in  wooden  or  vulcanite  tongs 
or  forceps,  and  are  saturated  in  the  above  fashion  in  the  methyl  chloride.  Bailly 
calls  the  forceps  for  holding  such  a  tampon  "Stype"  and  the  procedure  "Stypage." 
The  tampons  are  placed  upon  the  skin  at  the  point  to  be  anesthetized  and  left  there 
until  the  tissues  are  frozen,  which  usually  occurs  after  a  few  seconds.  By  means  of 
a  camel's-hair  brush  soaked  in  methyl  chloride  the  anesthesia  can  be  confined  to 
minute  areas.  This  agent  even  when  used  in  this  indirect  manner  can,  by  careless 
manipulation,  cause  destruction  of  tissue  (Feibes). 

Under  the  trade  names  of  Anastol,  Anastyl,  Metathyl,  Ivory  1,  various  mixtures  of 
ethyl  chloride  with  methyl  chloride  find  their  way  into  the  market.  They  act  more 
quickly  but  less  thoroughly  than  ethyl  chloride  and  are  used  in  the  same  manner. 

Still  greater  care  is  necessary  in  using  the  fluid  and  solidified  carbon  dioxide  rec- 
ommended by  Wiesendenger  and  Kuemmell,  for  anesthesia.  The  direct  application 
of  a  stream  of  this  fluid,  boiling  at  —78°  C,  upon  the  skin  is  naturaUy  prohibited. 
According  to  Wiesendenger  the  fluid  CO2  is  passed  into  a  metal  tube  or  the  container 
is  filled  with  closely  packed  CO2  snow.  Anesthesia  is  produced  by  contact  of  the 
metal  tube  with  the  skin.    Caution  is  also  necessary  with  this  method. 

Of  all  the  cold-producing  agents  referred  to,  pure  ethyl  chloride  next  to  the  ether 
spray  is  highly  recommended  and  has  rapidly  come  into  extensive  use.  The  small 
glass  containers  used  in  dispensing  ethyl  chloride  are  very  convenient  for  use,  and  the 
cost  small;  100  c.c.  costing  about  75  cents.  Inducing  anesthesia  by  freezing  the  skin 
or  mucous  membrane,  even  in  vascular  tissues,  is  produced  in  the  fraction  of  a  minute, 
injury  to  the  tissue  being  easily  avoided;  provided  proper  precaution  is  used.  The 
spray  of  ethyl  chloride  should  be  discontinued  as  soon  as  the  superficial  layers  of  the 
tissues  are  frozen,  as  continued  freezing  for  the  purpose  of  obtaining  deeper  anesthesia 
will  almost  always  result  in  permanent  injury  to  the  tissues.  Inducing  artificial 
anemia  in  the  part  to  be  anesthetized  is  very  essential  with  the  use  of  the  ether  spray, 
but  is  unnecessary  when  using  the  spray  of  ethyl  chloride,  as  the  cold  produced  by  the 
latter  is  so  intense  that  a  dermatitis,  vesiculation  or  superficial  gangrene  may  occur 
in  a  short  time  on  extremities  made  anemic  by  ligation.    Covering  the  skin  with 


ANESTHESIA   BY  MEANS  OF  COLD  51 

vaseline  or  ii;lyceriiie  as  recommended  by  many  does  not  n()ticeal)ly  reduce  tlie  effect 
of  the  cold.  It  serves  merely  to  protect  the  skin  from  chemical  irritation  of  the  anes- 
thetic agent,  as  when  using  sulphuric  ether.     Ethyl  chloride  does  not  irritate  the  skin. 

There  is  no  reason  to  use  fluids  having  a  lower  boiling-point  than  that  of  ethyl 
chloride,  the  supposed  advantage  of  a  more  rapid  anesthesia  being  more  than 
counterbalanced  by  the  shortening  of  the  anesthetic  effect.  The  use  of  Rich- 
ardson's spray  requires  slightly  more  time  to  freeze  the  skin  and  make  it  insensitive 
owing  to  the  slower  cooling  of  the  tissues,  but  the  deeper  parts  are  made  insensitive 
without  the  danger  of  injury  to  the  skin.  The  preceding  nerve  irritation  is  also 
lessened  the  slower  the  freezing  is  induced. 

The  inflammability  of  many  hydrocarbons  and  their  ^-apo^s  requires  great  caution. 
In  the  presence  of  an  open  flame  or  a  glowing  cautery  the  ether  spray  should  not  be 
used.  Fluid  methyl  chloride  or  ethyl  chloride,  though  combustible,  are  not  explosive 
and  their  vapors  will  not  ignite  in  an  open  flame.  Consequently  there  is  no  danger 
following  the  use  of  ethyl  chloride  spray  with  the  thermocautery.  Ethyl  bromide 
and  carbon  dioxide  are  not  at  all  inflammable.  Ethyl  chloride  having  pure  basic 
cocain  in  solution  has  recently  come  into  use  in  connection  with  the  latter  drug 
(Bardet),  but  inasmuch  as  ethyl  chloride  serves  merely  as  a  solvent  we  will  discuss 
this  mode  of  application   of    cocain  in   another  place. 

Anesthetizing  by  means  of  cold  has  the  advantage  of  simplicity  of  application. 
By  the  addition  of  tubes  of  ethyl  chloride  to  the  physician's  armamentarium  he  can 
without  much  previous  technical  training  induce  anesthesia  by  cold.  Care  must 
be  exercised  so  that  damage  to  the  tissues  does  not  occur,  although  this  is  not  to  be 
feared  in  parts  abundantly  supplied  with  blood.  The  usefulness  of  this  method  is 
curtailed  by  the  fact  that  the  anesthesia  does  not  penetrate  very  deeply  and  that  the 
healthy  and  diseased  tissues  are  not  easily  differentiated  after  being  frozen.  Another 
disadvantage  is  that  the  freezing  as  well  as  the  thawing  of  the  tissues  is  painful, 
especially  in  inflamed  and  hypersensitive  parts.  For  this  reason  the  production  of 
local  anesthesia  by  means  of  cold  has  from  its  introduction  until  the  present  day  been 
used  solely  for  short  and  suj^erficial  operations.  The  attempt  to  use  it  in  major 
surgery  has  been  limited  to  isolated  cases.  Dolbeau  made  a  resection  of  the  scapula 
with  satisfactory  results  by  the  repeated  application  of  the  ether  spray  to  the  cut 
surfaces.  This  method  must  be  considered  most  impractical  owing  to  the  imperfect 
anesthesia  in  most  cases  and  hemorrhage  not  being  controlled  by  the  ether  spray.  In 
large  part  the  cold  itself  is  a  disadvantage,  because  it  prevents  a  careful  dissection 
of  the  deeper  layers,  coats  the  instruments  with  ice,  and  robs  the  fingers  of  the 
sense  of  touch  (Kappeler). 

Spencer  Wells  attempted  an  ovariotomy  under  the  ether  spray.  The  abdominal 
incision  was  free  from  pain,  but   loosening  tiie  adhesions  necessitated  chloroform 


J 


52  LOCAL  ANESTHESIA 

anesthesia.  Richardson  and  Greenhalgh  completed  a  Cesarean  section  almost  pain- 
lessly by  aid  of  the  ether  spray.  There  is  no  doubt  that  of  all  the  major  operative 
work  the  abdomen  lends  itself  most  readily  to  this  method  of  anesthesia.  The  reason 
for  this  is  not  because  of  the  perfection  of  the  method,  but  owing  to  the  fact  that 
many  abdominal  operations  can  be  performed  painlessly.  If  the  skin  and  abdominal 
wall  are  made  insensitive,  the  subsequent  manipulations  often  give  little  discomfort. 
The  general  introduction  of  this  procedure,  recently  suggested  by  Bloch,  should  be 
accepted  with  the  same  misgivings.  Bloch  believes  that  the  anesthetizing  of  the  skin 
by  means  of  ethyl  chloride  suffices  for  many  major  operations  without  causing  the 
patient  much  pain.  He  reports  503  such  operations,  including  many  herniotomies, 
tracheotomies,  thoracotomies,  colostomies,  etc.  It  is  undoubtedly  true  that  in 
many  major  siu-gical  operations,  especially  abdominal  section,  the  skin  incision  is 
the  most  painful  part  of  the  operation,  and  this  can  be  rendered  insensitive  with  the 
aid  of  ethyl  chloride;  nevertheless  to  bear  up  under  the  subsequent  steps  of  the  opera- 
tion requires,  as  a  rule,  a  heroism  not  found  in  all  patients.  The  misgivings  of  all 
uncertain  and  imperfect  methods  of  anesthesia  are  also  to  be  noted  with  Bloch's 
method.  Anesthetizing  the  skin  incision  alone,  or  following  this  with  general  anes- 
thesia, can  be  replaced  by  methods  more  reliable  than  the  application  of  ethyl 
chloride. 

The  use  of  cold  as  a  local  anesthetic  can  generally  be  said  to  be  of  use  for  super- 
ficial incisions,  as  in  opening  an  abscess,  or  furuncle,  incising  fistulse,  aspirating  cav- 
ities of  the  body,  and  minor  operations  on  the  skin  and  mucous  membranes.  In  these 
conditions  when  the  skin  is  frozen,  the  anesthesia  is  often  insufficient,  owing  to  the 
deeper  tissues  being  made  sensitive  by  the  accompanying  inflammation,  all  pressure 
and  pulling  on  the  tissues  causing  intense  pain. 

It  is  often  possible  to  make  simple  extraction  of  teeth  more  bearable  or  even  pain- 
less if  the  gums  on  both  sides  of  the  alveolar  process  are  frozen  by  means  of  a  stream 
of  ethyl  chloride.  In  pulpitis,  on  account  of  the  presence  of  great  pain,  this  method 
is  not  applicable. 

The  fact  that  the  chilling  of  exposed  nerve  trunks  in  animals  can  interrupt  the 
transmission  of  sensation,  has  encouraged  experiments  on  human  subjects,  attempting 
by  freezing  the  skin  overlying  nerve  trunks  to  produce  conduction  anesthesia  in  the 
area  supplied  by  these  nerves.  The  possibility  of  so  influencing  superficially  situated 
nerve  trunks  can  be  easily  demonstrated  by  experiments  on  one's  own  body. 

In  one  case  the  ethyl  cliloride  spray  was  played  upon  the  ulnar  nerve  at  the  internal 
condyle  of  the  humerus.  After  freezing  the  skin,  the  spray  was  continued  about 
half  a  minute  before  the  nerve  trunk  was  affected.  Suddenly  intense  pain  developed 
in  the  entire  area  of  distribution  of  this  nerve,  followed  in  about  a  minute  by  a  feeling 
of  numbness  with  irregular  areas  of  anesthesia  on  the  forearm  and  the  fom-th  and  fifth 


I 


ANESTHESIA   BY  MEANS  OF  COLD  53 

fiii<;-ers.  On  account  of  the  severe  pains  it  was  inii)ossible  to  continue  the  freezing 
to  the  point  of  complete  interruption  of  nerve  conthiction.  Two  minutes  after  stop- 
j)ing  the  ethyl  chloride  spray  no  evidence  of  interruption  of  nerve  conduction  remained ; 
nevertheless,  at  the  point  of  application  blisters  and  a  painful  infiltrate  formed. 
Experiments  with  the  radial  nerve,  close  to  the  wrist,  proved  more  successful  in  so 
far  as  the  conduction  of  the  nerve  could  be  totally  interrupted.  It  was  shown  here, 
as  before,  that  as  soon  as  the  cold  reached  the  nerve,  severe  pains  ensued;  the  skin 
at  the  ])oint  of  ai)plication  of  the  ethyl  chloride  was  severely  damaged,  causing  the 
formation  of  a  painful,  slowly  healing  ulcer. 

As  before  mentioned,  the  ether  spray  is  more  suitable  than  ethyl  chloride  when 
deep  action  is  desired.  It  requires  several  minutes  to  cause  interruption  of  nerve 
conduction,  as  for  example,  in  experimenting  on  the  ulnar  or  radial  nerve,  the  ensuing 
pains  are,  as  with  ethyl  chloride,  very  severe,  but  the  damage  to  the  tissues  is  avoided. 
The  attempt  to  anesthetize  the  finger  by  the  use  of  the  ether  spray  applied  to  the  base 
was  without  result;  as  soon  as  the  chilling  of  the  tissues  penetrated  deeply,  the  pain 
became  unbearable.  The  practical  usefulness  of  conduction  anesthesia  produced 
by  freezing  the  nerve  trunks,  particularly  when  applied  to  the  larger  nerves,  has  not 
proved  of  much  value;  however,  a  reduction  of  sensibility,  if  not  total  anesthesia, 
can  be  obtained.  Experiments  in  this  direction  have  been  repeatedly  made,  Rossbach 
stating  that  he  succeeded  in  anesthetizing  the  superior  laryngeal  nerve  and  with 
it  the  trachea,  by  applying  the  ether  spray  for  two  minutes  to  both  sides  of  the  neck 
below  the  ends  of  the  hyoid  bone.  Scheller  and  von  Hacker,  for  the  extraction  of 
teeth,  do  not  allow  the  ethyl  chloride  spray  to  act  upon  the  gums,  but  externally 
upon  the  skin,  in  the  region  of  the  anterior  surface  of  the  lower  jaw,  canine  fossa, 
and  in  front  of  the  ear.  Both  authors  state  that  an  obtunding  or  total  anesthetic 
effect,  sufficient  for  the  extraction  of  teeth,  could  be  occasionally  obtained  in  this 
manner,  though  both  acknowledge  the  uncertainty  of  the  method. 

Local  anesthesia  by  means  of  cold  w^as  attempted  in  other  ways,  one  of  which  con- 
sisted in  injecting  cold  fluids  into  the  tissues.  Heinze  and  the  author  have  studied 
the  physiological  effects  produced  by  the  injection  of  fluids  of  different  temperatures 
into  their  own  skin  in  the  neighborhood  of  sensory  nerves.  We  used  for  this  purpose 
a  0.9  per  cent,  sodium  chloride  solution,  which,  injected  at  body  temperature,  caused 
neither  irritation  nor  loss  of  feeling  in  the  sensory  nerves.  It  was  shown  that  a 
decided  lowering  of  the  temperature  of  the  solution  below  that  of  the  body  produced 
a  corresponding  painful  irritation,  the  colder  the  solution  the  greater  the  pain.  Reduc- 
ing the  temperature  of  the  solution  to  0°  or  below  caused  pain,  following  which  anes- 
thesia occurred,  lasting  a  few  seconds;  whereas  solutions  of  a  higher  temperature 
produced  absolutely  no  diminution  of  sensation.  Injecting  large  areas  with 
solutions  at  0°  produced  more  decided  effects,  as  the  tissues  resumed  their  normal 


54  LOCAL  ANESTHESIA 

temperature  more  slowly.  Letang,  for  purposes  of  local  anesthesia,  injected  0.5  to 
1  per  cent,  of  chloride  of  sodium  at  0°  or  mixtures  of  water,  glycerin,  and  ether,  but 
these  methods  are  not  worthy  of  recommendation.  For  a  short  anesthesia  one  cannot 
expect  as  much  from  methods  of  this  kind  as  from  the  ether  or  ethyl  chloride 
spray,  the  latter  causing  rapid  cooling,  never  obtained  by  injecting  cold  solutions. 
Letang  claimed  that  by  repeated  injections  the  duration  of  the  anesthesia  may  be 
prolonged  indefinitely.  In  practice  this  would  be  a  decided  inconvenience  and  tend 
greatly  to  prolong  the  operation.  It  has  been  proposed  by  Schleich  to  use  cold  solu- 
tions of  cocaine  as  an  injection,  but  results  from  this  method  should  not  be  attributed 
to  the  direct  action  of  cold,  but  rather  to  a  retardation  of  absorption  from  the  chilled 
tissues,  thus  intensifying  the  action  of  the  cocaine.  The  use  of  cold  as  an  aid  to  various 
anesthetic  agents  will  be  discussed  in  Chapter  VIII. 


J 


CHAPTER   V. 

THE   EFFECT  OF  OSMOTIC  TENSION  OF  WATERY  SOLUTIONS 
INJECTED   FOR   PURPOSES  OF  LOCAL  ANESTHESIA. 

If  a  glass  cylinder,  closed  at  the  bottom  by  means  of  an  animal  membrane  and  filled 
with  a  concentrated  salt  solution,  be  suspended  in  a  \'essel  filled  with  pure  water 
so  that  the  surface  of  both  fluids  lie  in  the  same  plane,  an  exchange  of  molecules  will 
take  place  between  the  two  fluids;  the  water  passing  from  the  outer  to  the  inner  vessel 
and  the  salt  from  the  inner  to  the  outer  vessel.  The  former  being  much  stronger 
than  the  latter  causes  the  volume  of  water  in  the  inner  vessel  to  be  increased,  as  shown 
by  the  rise  of  its  surface.  This  exchange  continues  until  the  salt  solutions  in  both 
vessels  are  of  equal  concentration.  The  same  exchange  takes  place  when,  without 
the  interposition  of  a  membrane,  pure  water  is  poured  over  a  concentrated  salt  solu- 
tion. In  the  latter  case  we  speak  of  a  diffusion,  in  the  former  of  osmosis,  or  osmotic 
dift'usion.  The  energy  causing  the  exchange  of  molecules  and  the  rising  of  the  surface 
of  the  salt  solution  in  the  suspended  vessel  is  called  osmotic  pressure  or  osmotic  ten- 
sion. This  is  an  intrinsic  latent  physical  property  of  water  and  all  watery  solutions, 
and  is  dependent  upon  the  number  of  molecules  per  liter  and  their  degree  of  dissocia- 
tion. The  rapidity  of  diffusion  of  the  salt  solution  has  a  definite  relation  to  the  char- 
acter of  the  dissolved  substances,  the  concentration  of  the  salt  solution,  and  the  per- 
meability of  the  separating  membrane.  The  rapidity  of  diffusion  of  the  water  toward 
the  salt  solution  is  almost  in  proportion  to  the  concentration  of  the  latter  and  increases 
with  a  rise  in  temperature.  The  rapidity  of  movement  of  the  salt  solution  is  less 
dependent  on  change  of  temperature.  Colloids,  albumin,  mucous,  glue,  rubber,  etc., 
diffuse  with  difficulty  and  sparingly  through  dead  animal  membranes,  as  opposed 
to  the  crystalloid  substances  and  do  not  alter  the  osmotic  pressure  of  the  fluids  in 
which  they  are  dissolved.  If,  instead  of  pure  w^ater  and  a  salt  solution,  a  weak  and  a 
concentrated  solution  of  salt  are  so  placed  as  to  act  one  upon  the  other,  a  movement 
of  water  takes  place  from  the  weaker  to  the  more  concentrated  solution,  the  salt 
passing  in  the  opposite  direction.  The  rapidity  of  exchange  will  in  this  instance, 
other  things  being  equal,  be  proportionate  to  the  difference  in  concentration  of  the 
two  solutions. 

When  solutions  of  different  salts  are  placed  together  one  will  find  in  each  a  solution 
of  the  other  salt,  but  inasmuch  as  there  is  no  interchange  of  water  the  concentration 


56  LOCAL  ANESTHESIA 

of  the  solutions  is  not  altered.  Solutions  having  the  same  osmotic  pressure  are  called 
isosmotic  or  isotonic;  if  one  of  the  solutions  be  diluted  by  the  addition  of  water,  it  is 
said  to  be  hyposmotic  or  hypotonic,  and  gives  off  water  to  the  more  concentrated 
solution;  if  the  solution  be  made  more  concentrated,  it  is  called  hyperosmotic,  or 
hypertonic,  and  absorbs  water  until  both  solutions  are  again  isotonic.  An  inter- 
change of  the  molecules  of  different  salts  in  solution  occurs  at  the  same  time,  and 
independently  of  the  movement  of  water,  even  if  the  solutions  be  isotonic,  so  that 
eventually  the  salt  molecules  on  both  sides  will  be  equal.  These  osmotic  changes 
are  constantly  taking  place  throughout  nature,  wherever  living  cells  and  body  fluids 
come  into  contact  with  one  another.  The  modus  operandi  by  which  the  organism 
maintains  a  constant  and  definite  salt  content  in  the  body  juices,  under  normal  con- 
ditions, has  recently  been  given  much  study  and  bids  fair  to  be  of  great  significance 
in  future  pathology  and  therapy. 

The  proper  functioning  of  nerve  elements,  in  fact  all  living  tissues,  is  known  to  be 
dependent  upon  their  being  immersed  in  a  nutritive  solution,  consisting  of  water, 
albuminous  substances,  and  salts.  The  composition  of  this  solution  must  not  only 
be  of  definite  chemical  and  physical  constancy,  but  likewise  of  definite  temperature 
and  concentration  of  its  salt  content,  etc.,  as  determined  by  its  osmotic  pressure. 

The  concentration  of  the  salt  content  varies  in  different  animals  and  plants.  It 
is  of  much  interest  to  know  that  living  tissues,  especially  nerve  elements,  can  be  kept 
alive  in  certain  watery  solutions  having  a  definite  salt  content,  without  otherwise 
corresponding  in  their  chemical  composition  to  the  nutrient  fluids,  so-called  physio- 
logical solutions,  whereas  slight  changes  in  the  salt  content  occasion  a  rapid  loss  of 
function  and  change  of  form  of  the  tissues.  The  cause  of  these  conditions  is  dependent 
upon  the  presence  or  absence  of  osmotic  tension  between  the  salt  solution  and  the 
body  fluids.  The  solutions  in  which  the  form  and  function  of  the  tissues  is  best 
preserved  are  those  which  are  isotonic  with  the  normal  nutrient  fluids. 

Nasse  was  the  first  to  make  attempts  in  this  direction.  By  placing  the  muscles  of 
frogs  in  salt  solutions,  he  demonstrated  in  which  concentration  their  irritability  was 
longest  preserved.  Solutions  found  to  be  best  suited  for  this  purpose  were  solution 
of  0.6  per  cent,  sodium  chloride,  1.75  per  cent,  solution  of  sodium  iodide,  1  per  cent, 
solution  of  sodium  nitrate.  These  solutions  and  frogs'  blood  ha^-e  almost  the  same 
osmotic  pressure. 

De  Vries  was  the  first  to  accurately  describe  isotonics.  He  determined  the  isosmotic 
concentration  of  a  large  number  of  organic  and  inorganic  combinations,  and  studied 
their  relations  to  molecular  weight.  The  discovery  of  isotonicism  resulted  from  the 
ob.servation  that  watery  solutions  of  whatever  composition,  but  of  definite  concen- 
tration, produced  phenomena  in  plants  which  could  only  be  caused  by  dehydration 
(plasmolysis)    of   plant   cells  and   young   sprouts.     The   weakest   concentration   of 


THE  EFFECT  OF  OSMOTIC   TENSION  OF   WATERY  SOLUTIONS  57 

solutions  able  to  produce  the  above  described  dehydration  are  said  to  be  isotonic 
to  one  another. 

In  a  similar  manner,  Hamburger,  Koeppe  and  Iledin,  by  i)hysiological  experiments 
with,  the  red  corpuscles  of  various  animals  and  man,  noted  the  swelling  and  dehydra- 
tion of  the  corpuscles  under  the  microscope,  and  in  this  way  were  able  to  determine 
the  isotonic  concentration  of  aqueous  solutions.  Hamburger  determined  first  the 
concentration  in  which  the  red-blood  corpuscles  w^ere  most  quickly  and  completely 
precipitated,  and  the  weakest  concentration  causing  hemolysis ;  the  mean  of  these  two 
\'alues  being  identical  with  De  Vries'  results  regarding  the  isotonic  concentration  of 
the  various  salt  solutions.  Koeppe  and  Hedin  by  certain  special  methods  made  use 
of  the  volumetric  change  in  the  red  corpuscles  for  the  determination  of  the  isotonicity 
of  solutions;  with  hypotonic  solutions,  the  volume  being  increased,  and  with  hyper- 
tonic solutions  diminished  in  volume.  These  interesting  physiological  methods  are 
used  very  seldom  today,  as  physical  chemistry  has  devised  simpler  and  more  exact 
methods  for  the  determination  of  osmotic  tension  of  fluids. 

Osmotic  tension  is  most  easily  determined  by  finding  the  freezing-point  of  water 
holding  crystaloid  substances  in  solution.  Solutions  having  the  same  freezing-point 
are  called  isomotic.  Osmotically  indifferent,  in  reference  to  the  absorption  and  giving 
up  of  water  in  their  action  upon  human  tissues,  are  those  solutions  having  the  same 
freezing-point  as  the  normal  body  fluids,  for  example,  the  blood.  The  determination 
of  the  freezing-point  of  human  blood,  lymph,  transudates,  exudates,  were  first  made 
by  Dreser,  later  by  Hamburger,  Koranyi,  Tauszk,  Winter,  and  the  author.  The 
determination  of  the  freezing-point  of  the  blood  has  of  late  become  an  important 
method  of  clinical  research. 

The  freezing-point  of  the  blood  of  healthy  individuals  was  found  l)y  Dreser  to  be 
—  0.56°;  Hamburger,  —0.55°;  Koranyi,  —  0.5G°;  Winter,  —0.55°. 

The  mean  freezing-point  of  the  blood  is  held  by  most  investigators  to  be  —0.56° 
although  the  mean  value  as  determined  by  some  is  placed  at  —0.55°.  Variations  from 
these  figures,  above  or  below,  are  exceedingly  small  under  normal  conditions.  Values 
of  -0.54°  and  -0.57°  can  hardly  occur  in  healthy  individuals;  in  certain  diseases 
variations  of  a  few  hundredths  of  a  degree  above  or  below  are  noticed. 

Watery  solutions,  therefore,  with  a  freezing-point  of  —0.55°  to  —0.56°  have  approxi- 
mately the  same  osmotic  pressure  as  human  blood.  Solutions  with  a  freezing-point 
near  0°  are  hyposmotic,  those  with  a  lower  freezing-point  than  —0.55°  are  hyper- 
osmotic, compared  to  the  nutrient  fluids  of  the  human  body.  ^Monocellular  plants 
and  animals  can  live  in  water  without  tumefaction  of  their  structure  or  undergoing 
any  change  of  their  salt  content  by  reason  of  the  structure  of  their  encapsulating 
membrane.  In  the  same  manner  epithelium  of  the  skin  and  that  of  most  mucous 
membranes  protects  the  human  tissues  from  the  action  of  solutions  of  varying  osmotic 


58  LOCAL  ANESTHESIA 

pressure.  If  such  solutions,  however,  are  brought  into  intimate  contact  with  wounds 
or  injected  into  the  tissues,  osmosis  will  take  place,  according  to  the  physical  experi- 
ments previously  mentioned  with  plant  cells  and  red-blood  corpuscles,  resulting  in 
their  change  of  volume.  Hyposmotic  solutions  cause  cells  and  other  tissue  structures 
to  swell,  hyperosmotic  solutions  by  their  dehydrating  action  cause  them  to  shrink, 
producing  what  is  called  plasmolysis.  The  more  the  solutions  vary  in  their  freezing- 
point  from  that  of  the  blood,  the  greater  the  osmotic  change  in  the  tissues. 

Tumefaction  as  well  as  dehydration  influences  the  action  of  the  sensory  nerves  and 
injures  the  tissues  irrespective  of  the  substances  in  solution.  Experiments  have  been 
carried  out  by  the  author  and  confirmed  by  Heinze  in  reference  to  the  physiological 
effect  of  the  differences  of  osmotic  tension.  For  this  purpose  injections  of  lukewarm 
water  and  salt  solutions  of  varying  degrees  of  concentration  were  injected  into  his 
skin  and  that  of  other  subjects.  If  a  fluid  is  injected  into  the  dense  tissues  of  the  skin 
by  means  of  a  needle  passed  parallel  to  its  surface,  avoiding  the  loose  subcutaneous 
connective  tissue,  a  round,  pale  wheal  raised  above  the  surface  of  the  surrounding 
skin  will  be  immediately  apparent.  Changes  of  sensation  in  this  wheal,  produced 
by  the  injection  of  a  foreign  fluid,  can  be  readily  tested  in  consequence  of  the  rich 
nerve  supply  of  the  skin.  Wheals  produced  in  this  manner  were  first  used  by  Schleich, 
but  the  credit  for  the  practical  adaptation  of  this  method  must  be  given  to  Heinze, 
The  observations  made  by  Schleich  upon  the  skin  wheal  have  been  proved  very 
indefinite  by  control  experiments  made  by  many  others.  The  results  of  our  experi- 
ments are  shown  in  the  table  (Fig.  4). 

On  the  horizontal  line  chloride  of  sodium  solutions  are  noted,  varying  in  strength 
from  0  per  cent,  (water)  to  10  per  cent.;  the  freezing-point  for  a  number  of  these  solu- 
tions is  also  shown.  The  curve  designated  by  the  solid  line  denotes  sensory  irritation, 
evidencing  itself  as  pain  when  the  solution  is  injected  into  the  skin;  the  dotted  curve 
represents  paralysis  of  sensation,  anesthesia  having  followed  the  irritation.  Points 
on  the  curve  denote  the  relative  intensity  of  irritation  and  paralysis.  Salt  solution 
of  0.9  per  cent,  occupies  a  middle  position  in  the  chart  having  a  freezing-point  of 
—  0.55°  and  therefore  having  about  the  same  osmotic  tension  as  the  human  blood. 
All  solutions  placed  to  the  left  of  this  point  cause  swelling  of  the  tissues,  those  to  the 
right  causing  dehydration.  If  a  0.9  per  cent,  solution  of  lukewarm  sodium  chloride 
is  injected  into  the  skin  neither  pain  nor  irritation  follow,  there  is  no  alteration 
of  sensibility  in  the  skin  of  the  wheal,  at  least  there  is  no  diminution  of  sensation, 
the  wheal  disappearing  in  a  short  time  without  leaving  any  evidence  of  its  previous 
existence.  If  the  concentration  of  the  solution  is  now  reduced  to  0.55  per  cent,  pain 
occurs  upon  injection,  which  is  increased  upon  a  further  reduction  of  the  strength 
of  the  solution,  becoming  very  severe  when  pure  water  is  used.  The  pain  following 
these  injections  is  called  the  pain  of  tumefaction,  which  is  of  short  duration,  followed 


THE  EFFECT  OF  OSMOTIC   TENSION  OF   WATERY  SOLUTIONS  59 


60  LOCAL  ANESTHESIA 

by  a  diminution  or  loss  of  sensation  in  the  area  in^'olved.  It  is  increased  in  intensity 
and  duration  by  a  reduction  of  the  concentration  of  the  sokition.  The  use  of  pure 
water  causes  anesthesia  of  the  longest  duration,  lasting  about  fifteen  minutes.  This 
is  called  tumefaction  anesthesia.  Weak  salt  solutions  may  cause  damage  to  the  tissues, 
painful  infiltrations  remaining;  pure  water  frequently  causes  superficial  necrosis, 
so-called  tumefaction  necrosis.  With  the  use  of  solutions  containing  more  than  0.9 
per  cent,  of  sodium  chloride,  symptoms  of  dehydration  will  be  noted  such  as  irritation, 
paralysis,  or  damage  to  the  tissues.  The  irritation  from  this  solution  is  quite  different 
from  the  pain  of  tumefaction.  It  follows  a  comparatively  painless  injection  lasting 
several  minutes,  the  wheal  becoming  markedly  hyperesthetic,  and  is  then  followed 
by  anesthesia.  During  this  time  the  swelling  undergoes  peculiar  and  typical  changes 
of  form.  With  the  subsidence  of  the  burning  pain  and  the  beginning  of  anesthesia, 
the  wheal  sinks  quickly  in  the  centre,  the  margins  remaining  elevated  in  the  form 
of  a  circular  ridge.  The  anemic  centre  and  surrounding  margin  are  separated  by  a 
narrow  red  ring.  In  about  fifteen  minutes  the  swelling  flattens  out  uniformly,  extend- 
ing from  the  centre  toward  the  periphery,  and  sensation  gradually  returns.  Concen- 
trated salt  solutions  furthermore  injure  the  tissues.  The  intensity  of  all  these  phe- 
nomena increases  with  the  concentration  of  the  salt  solution.  They  are  noticeable  at 
2.5  per  cent,  and  more  than  10  per  cent,  salt  solution  can  hardly  be  borne.  In  the  dia- 
gram on  each  side  of  the  0.9  per  cent,  salt  solution,  is  noted  the  so-called  indifferent 
zone  in  which  a  number  of  solutions  from  0.55  to  2.5  per  cent,  do  not  produce  notice- 
able swelling  or  dehydration  of  the  tissues,  or  any  of  the  symptoms  above  mentioned. 
The  curve  indicating  pain  and  paralysis  naturally  does  not  represent  absolute  values, 
and  was  determined  by  experiments  carried  out  upon  the  skin  of  our  forearms.  When 
salt  solution  is  injected  into  the  tissues  of  very  sensitive  persons,  or  into  hyperesthetic 
areas,  weak  solutions  must  be  used  to  avoid  swelling  or  dehydration  of  the  tissues. 
In  this  manner  the  pain  and  anesthesia  curve  will  approach  the  horizontal,  nearer  to 
the  middle  point  than  has  pre^'iously  been  shown,  and  the  indifferent  zone  will  be 
narrower. 

That  these  are  the  real  symptoms  of  tumefaction  and  dehydration,  we  may  conclude 
from  the  following  circumstance.  Inasmuch  as  water  and  salt  are  constantly  present  in 
the  body  and  act  chemically  upon  the  tissues  very  slightly,  we  must  consider  the  pain, 
paralysis,  and  injury  to  the  tissues  as  due  to  the  physical  properties  of  the  solution. 
The  symptoms  must  be  due  to  the  osmotic  tension  of  the  solutions,  as  the  symptoms 
vary  with  the  change  of  osmotic  pressure,  and  disappear  when  osmotic  tension  between 
the  blood  and  the  solutions  is  equal.  There  are  a  number  of  other  salts  which 
chemically  react  slightly  or  not  at  all  upon  the  tissues.  To  these  belong  most  of  the 
sodium  salts,  as  phosphates,  carbonates  and  borates,  also  sugar  and  some  of  the  urea 
compounds.    The  solutions  of  these  salts  have  been  examined  systematically  in  the 


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THE  EFFECT  OF  OSMOTIC  TENSION  OF   WATERY  SOLUTIONS  (H 

foregoing-  way,  and  found  to  have,  like  tlie  ehloride  of  sodium,  an  indifferent 
zone  as  determined  by  the  freezing-point,  isotonic  with  the  blood  or  physiological 
solutions,  and  that  their  solutions  produce  the  same  symptoms  as  salt  solutions  with 
a  like  freezing-point,  from  tumefaction  pain  to  the  peculiar  change  of  form  of  the 
wheal  due  to  the  strong  dehydrating  actions  of  the  solutions.  For  this  reason  the 
curves  for  irritation  and  paralysis  are  applicable  for  w^atery  solutions  of  all  substances. 
The  symptoms  of  their  physical  effect  are  often  obscured  in  consequence  of  their 
difference  chemically,  irritating  or  paralyzing  the  sensory  nerves,  damaging  or  destroy- 
ing the  tissues.  It  is  in  this  case  necessary  to  find  the  freezing-point  of  the  solution, 
in  order  to  determine  physical  effect  upon  the  tissues. 

In  Fig.  4  the  freezing-points  of  watery  solutions  of  a  few  other  salts  are  charted 
in  their  respective  positions.  We  see  that  the  physiological  concentration  of  cane  sugar 
is  about  8.5  per  cent.  This  solution  is  totally  indifferent  and  causes  upon  injection 
neither  pain  nor  anesthesia.  The  solutions  frequently  used  for  injection  beneath 
the  skin  are  very  dilute  and  must  necessarily  cause  pain,  owing  to  the  differences 
in  osmotic  tension.  The  table  show^s,  furthermore,  the  freezing-point  of  several 
anesthetic  solutions  to  W'hich  we  shall  return  later. 

For  a  considerable  period  of  time,  ever  since  anatomic  and  physiological  studies 
were  followed,  it  has  been  known  that  water  itself  has  the  elements  of  a  protoplasmic 
poison,  that  it  destroys  the  structure  of  those  cells  not  protected  by  an  impermeable 
membrane.  The  injurious  effect  of  swelling  can  be  observed  under  the  microscope; 
the  tissues  saturated  with  water  increase  in  volume,  lose  their  structure,  the  sarco- 
lemma  of  muscle  fiber  ruptures,  and  nerve  fibers  are  completely  destroyed.  This 
change  of  form  or  total  destruction  of  tissue  was  long  knowui  to  the  older  anatomists. 
It  has  also  long  been  known  to  physiologists  that  the  function  of  the  tissues  is 
destroyed  by  sw'elling  consequent  upon  immersion  in  water,  or  by  their  desiccation. 
Concentrated  salt  solutions  can  likewise  injure  the  tissues  by  their  dehydrating 
action.  Fresh  muscles  w^hen  placed  in  water  lose  their  properties  of  contraction  and 
response  to  stimuli,  becoming  rigid  (Swammerdam). 

Tumefaction  and  dehydration,  when  aftecting  a  ner\e  trunk,  act  as  a  stimulus 
and  lower  its  excitability.  Water  injected  between  the  fibers  of  a  nerve  trunk  at  once 
interrupts  conductivity  and  seriously  injures  it  (Biberfeld).  The  fact  that  these 
phenomena  failed  to  appear  when  definite  quantities  of  salts  were  dissolved  in 
the  water  led  finally  to  the  discovery  of  the  isotonicity  of  solutions  and  their  con- 
nection with  the  molecular  weight  of  the  dissolved  body.  This  was  of  far- 
reaching  importance  to  theoretical  chemistry,  and  van  t'Hoffts  theory  of  solutions 
is  dependent  upon  this  work  of  De  Vries  and  Hamburger. 

Saturating  the  body  of  animals  with  water  causes  severe  general  symptoms,  in 
consequence  of  the  diminution  of  osmotic  tension  of  the  blood  and  body  fluids. 


62  LOCAL  ANESTHESIA 

According  to  Falck,  dogs  are  killed  by  the  intravenous  injection  of  88  c.c.  of  water 
per  kilo  of  body  weight.  Subcutaneous  injections  of  about  200  c.c.  of  water  cause 
death  in  rabbits,  with  symptoms  of  difficult  respiration,  impaired  heart  action,  sub- 
normal temperature,  convulsions,  and  hemoglobinuria  (Falck,  Emmerich).  Custer 
made  the  same  observations  upon  injecting  rabbits  subcutaneously  with  large  quan- 
tities of  a  very  weak  cocain  solution.  The  animals  died,  not  as  a  result  of  cocain 
poisoning  but  in  consequence  of  the  absorption  of  water,  a  consequences  which  could 
have  been  avoided  by  the  addition  of  salt. 

The  prevailing  opinion  seems  to  be  that  a  0.6  per  cent,  salt  solution  is  the  most 
suitable  fluid  to  use  in  connection  with  the  tissues  of  the  body  and  has  therefore  been 
called  physiological  salt  solution.  Hamburger  and  Koeppe  called  attention  to  the 
fact  that  this  solution,  used  in  the  previously  mentioned  experiments  of  Nasse  on 
frog  muscles,  still  produced  tumefaction,  while  a  salt  solution  of  0.92  per  cent,  pro- 
duced the  same  osmotic  tension  as  the  human  blood.  A  0.6  per  cent,  salt  solution  is 
therefore  physiological  for  frogs,  and  a  0.92  per  cent,  salt  solution  is  physiological 
for  man. 

The  observation  that  the  subcutaneous  injection  of  water  relieves  pain  has  been 
verified  by  many.  The  first  of  these  observations  dates  from  Potain  (1869)  and  Dieu- 
lafoy  (1870).  Lafitte  states  he  has  achieved  good  results  in  various  painful  affections, 
as  sciatica,  neuralgia,  and  rheumatism,  by  water  injected  directly  into  the  affected 
part;  the  occurrence  of  severe  burning  pain,  though  of  short  duration  was  the  only 
unpleasant  feature.  The  soothing  effect  he  ascribed  to  the  compression  produced 
by  the  injected  fluid,  or  to  the  inhibition  of  water  by  the  sensory  nerve  fibers,  whereby 
the  latter  momentarily  lost  their  ability  to  receive  and  transmit  their  impressions. 
Similar  communications  have  been  received  from  Lelut,  Burneys,  Yes,  and  Griffith. 

Liebreich  and  Schleich  have  observed  that  water  produces  irritation,  to  be  followed 
by  anesthesia,  likewise  the  indifference  of  these  solutions  upon  the  addition  of  salt, 
and  finally  the  anesthetic  action  of  very  concentrated  salt  solutions. 

Under  the  guidance  of  Liebreich,  Bussenius  conducted  animal  experiments  in 
order  to  determine  the  local  anesthetic  effect  produced  by  different  substances.  He 
injected  these  solutions  subcutaneously  into  rabbits  and  found  that  while  0.6  per 
cent,  chloride  of  sodium  solution  produced  no  alteration  of  sensation,  5  per  cent,  and 
10  per  cent,  solutions  did  so  to  a  slight  degree.  We  have  shown  above  that  more 
exact  results  can  be  obtained  by  experimenting  on  one's  own  body,  using  Schleich's 
method.  Schleich  believed  that  there  must  be  a  solution  of  such  concentration 
between  pure  water  and  a  0.6  per  cent,  salt  solution  which  would  not  provoke  pain 
upon  injection;  but  on  account  of  similarity  to  pure  water  it  would  later  produce 
anesthesia,  and  he  thought  that  he  had  found  a  useful  anesthetic  in  the  0.2  per  cent, 
salt  solution.     The  anesthesia  and  pain  of  tumefaction  are  closely  associated  with 


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THE  EFFECT  OF  OSMOTIC   TENSION  OF   WATERY  SOLUTIONS  03 

one  aiiotlicT.  If  the  tuniefyint;-  action  of  the  water  is  reduced,  the  i)ain  is  lessened 
and  the  anesthesia  is  unsatisfactory. 

Tumefaction  anesthesia  has  been  seldom  used  in  performing  operations,  it  has 
been  occasionally  attempted  by  Halstead  and  Gant.  Schleich  reports  that  he  has 
been  able  with  the  aid  of  injections  of  water  to  excise  a  carbuncle  painlessly.  Isolated 
attempts  were  later  made  by  him  to  produce  local  anesthesia  by  the  injection  of  0.2 
per  cent,  salt  solution.  The  injection  of  this  solution  is  always  very  painful,  its 
consequent  anesthesia  imperfect,  and  of  very  short  duration.  An  anesthetic  which 
necessitates  pain  for  its  induction  has  been  called  by  Liebreich  "anesthesia  dolorosa." 
Tumefaction  anesthesia  can  be  called  an  anesthesia  dolorosa,  and  owing  to  its  injuri- 
ous action  upon  the  tissues  is  practically  useless.  The  results  of  our  researches 
concerning  the  physical  by-efi'ects  of  watery  solutions  may  be  classified  in  the 
following  manner : 

Injections  into  the  tissues  for  whate\er  purpose  must  be  composed  of  fluids  of  the 
same  osmotic  tension  and  freezing-point  as  the  body  fluids.  Inasmuch  as  solutions 
for  local  anesthesia  must  be  used  more  dilute  than  their  physiological  strength,  a 
corresponding  quantity  of  an  indifferent  salt,  as  sodium  chloride,  must  be  added  to 
prevent  any  injurious  action  upon  the  tissues. 


CHAPTER   VL 

ACTIVE  AND   INDIFFERENT  SUBSTANCES.    ABSORPTION  AND 

LOCAL  POISONING.    TESTS,   GENERAL  PROPERTIES,  AND 

METHODS  FOR   USING  LOCAL  ANESTHETICS. 

In  the  preceding  chapter  we  studied  the  effect  of  certain  substances  which  did  not 
produce  noticeable  changes  in  the  tissues,  thereby  making  possible  a  study  of  the 
physical  effects  of  their  watery  solutions  when  injected  into  the  tissues.  Let  us  now" 
consider  the  ultimate  result  of  these  substances  wdien  injected  into  the  tissues.  A 
small  part  may  find  its  way  at  once  into  a  vein  or  lymph  space  and  be  quickly  taken 
up  by  the  circulation;  the  larger  part,  however,  remains  at  the  point  of  injection,  being 
slowly  absorbed  after  a  more  or  less  extensive  diffusion  into  the  surrounding  tissues, 
"without  causing  any  noticeable  local  change. 

When  osmotic  differences  of  tension  are  present,  there  is  a  tendency  on  the  part 
of  the  body  to  equalize  them,  at  least  the  interesting  investigations  of  Hamburger 
regarding  the  absorption  of  watery  solutions  from  serous  cavities  seem  to  support 
this  theory.  In  this  connection  Hamburger  noticed  the  following:  (1)  Serous 
fluids  and  salt  solution  placed  in  the  abdominal  cavity  of  animals  are  absorbed.  (2) 
These  fluids  do  not  change  the  osmotic  tension  of  the  blood  of  the  animal  when  iso- 
tonic. (3)  Hypotonic  and  hypertonic  solutions  become  isotonic  in  the  abdominal 
cavity  during  absorption.  (4)  While  present  in  the  abdominal  cavity  there  is  a 
molecular  exchange  between  the  solution  and  the  blood  plasma. 

After  the  injection  of  an  isotonic  L7  per  cent,  solution  of  sodium  sulphate  into 
a  rabbit,  a  considerable  amount  of  chloride  of  sodium,  sodium  phosphate,  and  albumin 
are  found  in  the  remaining  isotonic  solution.  Hamburger's  experiments  do  not 
show  that  the  absorption  of  the  dissolved  substance  is  delayed  when  differences 
in  osmotic  tension  between  the  solution  and  the  blood  plasma  exist.  Hamburger 
expressly  states  that  the  equalizing  of  the  pressure  differences  takes  place  during 
but  independent  of  the  absorption.  This  is  not  without  practical  interest,  because 
it  has  been  erroneously  assumed  (Legrand)  that  cocaine  is  absorbed  more  slowly 
from  hypotonic  than  isotonic  solutions,  and  that  for  this  reason  the  use  of  isotonic 
solutions  is  of  no  particular  advantage. 

The  investigation  of  Schnitzler  and  Ewald  likewise  show  that  the  rapidity  of  absorp- 
tion is  dependent  upon  the  concentration  of  the  salt  solution.  It  can  be  shown  that 
a  definite  quantity  of  a  salt  (iodide  of  potash,  salicylic  acid)  is  more  rapidly  excreted 


METHODS  FOR   rsiXG   LOCAL   ANESTHETICS  65 

by  the  kidneys,  and  therefore  more  rapidly  absorbed  the  more  eoneentrated  the 
solution  introduced  into  the  abdominal  cavity.  The  great  rapidity  with  which 
substances  introduced  into  the  abdominal  cavity  reappear  in  the  urine  \-erifies 
the  important  observations  made  by  Klapp,  Heidenhain,  Orlow,  Starling,  Tubby, 
O.  Cohnheim,  and  others,  that  the  absorption  from  serous  cavities  of  substances 
dissolved  in  water  takes  place  principally  through  the  circulation.  The  authorities 
mentioned,  contrary  to  the  belief  of  Hamburger  and  Cohnstein,  hold  it  as  undoubtedly 
proved,  that  in  addition  to  osmosis,  and  filtration  under  increased  intraperitoneal 
pressure,  the  vital  forces  of  the  living  abdominal  wall  play  a  leading  part,  and  must 
influence  the  merely  physical  processes  concerned  in  the  absorption  from  the 
abdominal  cavity. 

The  phenomenon  of  absorption  of  injected  watery  solutions  from  the  subcutaneous 
connective  tissue  does  not  differ  materially  from  what  takes  place  in  the  abdominal 
cavity.  Independent  of  the  water,  which  causes  swelling  or  shrinking  of  the  tissues, 
an  interchange  of  molecules  takes  place  between  the  salts  in  the  solutions  and  the 
tissue  fluids,  as  in  a  physical  experiment.  In  fact,  an  osmotic  indifferent  salt  solution 
is,  in  this  respect,  not  entirely  indifferent,  as  the  tissue  fluids  contain  other  substances 
than  salt;  in  fact.  Hamburger  found  that  the  red-blood  corpuscles  will  give  up  their 
coloring  matter  in  such  a  solution.  According  to  Hoeber's  observations,  an  isotonicity 
of  the  body  fluids  would  be  temporarily  disturbed  by  this  solution.  The  amount  of 
the  dissolved  substance  diffused  in  the  region  of  injection  in  a  unit  of  time  must 
be  dependent  upon  the  concentration  of  the  solution  and  the  diffusibility  of  the  sub- 
stance, which  in  turn  is  influenced  by  the  varying  permeability  of  the  membranes 
and  skin  with  which  it  comes  in  contact.  If  the  injected  solution  be  under  great 
pressure,  it  will  by  means  of  simple  filtration  escape  into  the  surrounding  tissue.  The 
process  by  which  finally  the  largest  part  of  the  dissolved  substance  as  well  as  the 
solvent  enters  the  circulation,  that  is,  absorption,  is  surely  a  vital  process;  it  is  asso- 
ciated with  the  vitality  of  the  tissues,  taking  place  slowly  in  those  with  impaired 
vitality,  much  more  quickly  in  the  presence  of  active  metabolism,  and  entirely  absent 
in  lifeless  tissues.  It  is  an  established  fact  that  watery  solutions  absorbed  from  the 
subcutaneous  connective  tissue  enter  the  circulation  in  largest  part  without  the 
assistance  of  the  lymph  vessels  (^lagendie,  Lebkuechner,  Asher,  Munk,  Hamburger) ; 
whereas,  on  the  other  hand,  oily  solutions  are  almost  entirely  absorbed  by  the  lymph 
vessels,  in  consequence  of  w^hich  absorption  takes  place  more  slowly. 

Opposing  the  previously  mentioned  indifferent,  or  almost  indifferent,  substances, 
solutions  of  which  exert  a  physical  reaction  on  living  tissues,  are  an  endless  number 
of  other  substances  which  cause  other  than  physical  changes  in  the  tissues,  due  to 
their  chemical  composition.  All  of  these  changes  may  be  grouped  under  the  head 
of  local  poisoning,  and  give  evidence  of  their  presence  in  the  living  body  by  an  increase, 
5 


66  LOCAL  ANESTHESIA 

a  disturbance  or  loss  of  function,  stimulation  or  paralysis  of  sensory  nerves,  tissue 
injury,  or  local  death.  These  symptoms  are  sometimes  transient,  that  is,  after  a  cer- 
tain time,  the  living  tissues  are  able  in  some  way  or  other  to  dispose  of  the  foreign 
substances  affecting  function  or  threatening  the  life  of  the  structure,  and  again  take 
up  their  former  activities  practically  unchanged.  In  most  cases  the  local  poisoning 
causes  permanent  changes  resulting  in  a  more  or  less  severe  injury,  inflammation,  or 
necrosis  of  the  tissues.  The  majority  of  all  active  substances  cause  the  tissues  at  the 
seat  of  their  activity  to  become  hyperemic,  some  do  not  appreciably  change  the  blood- 
content,  some  few  induce  a  contraction  of  the  bloodvessels  and  make  the  tissues 
anemic.  Many  finally  bring  about,  immediately  following  their  application,  peculiar 
transient  local  edema,  a  symptom  at  once  recognized  by  any  one  remembering  the 
effects  of  insect  bites. 

The  process  of  absorption  must  progress  differently  with  active  than  with  inactive 
substances,  as  the  local  changes  as  described  can  hardly  be  conceived  without  a  loss 
of  substance;  a  local  action  can,  as  a  rule,  only  take  place  when  a  portion  of  the  active 
substance  is  chemically  combined  with  the  structures  in  the  immediate  locality 
and  is  thus  prevented  from  being  carried  into  the  circulation.  What  ultimately 
becomes  of  the  remaining  portion  of  most  substances  is  unknown.  Concerning  cer- 
tain alkaloids  it  is  known  that  after  their  incorporation  with  the  living  tissues  they 
are  not  absorbed  in  their  original  form,  but  that  the  organism  eliminates  them  by 
disintegration;  cocain  and  suprarenin  belong  to  this  group.  In  this  manner  the 
living  body  is  freed  from  poison.  The  more  slowly  a  substance  is  absorbed  from  the 
place  of  application  the  more  thorough  is  the  permeation  of  the  tissues,  and  the  more 
intense  and  extensive  the  local  action  than  when  more  quickly  eliminated  by  a  rapid 
absorption.  It  is  therefore  of  importance  for  us  to  study  the  methods  of  producing 
a  retardation  of  absorption  as  an  important  aid  to  local  anesthesia. 

When  chemically  active  substances  are  brought  into  contact  with  sensory  nerves, 
they  invariably  bring  about  a  transient  or  lasting  paralysis,  namely,  anesthesia, 
usually  preceded  by  a  state  of  severe  irritability.  Some  few  substances  have  been 
found  which  produce  local  poisoning  with  transient  sensory  paralysis,  without  irri- 
tation or  injurj^  to  the  tissues.  These  are  the  substances  useful  in  the  practical 
application  of  local  anesthesia. 

The  research  methods  having  for  their  object  the  determining  of  the  local  anesthetic 
properties  of  various  substances,  are  uncertain  because  of  the  fact  that  the  local 
anesthetic  power  of  a  substance  is  dependent  in  large  measure  upon  the  place  and 
method  of  application.  The  first  attempts  in  this  direction  were  associated  with  the 
belief  that  if  inhalation  anesthetics  were  brought  into  direct  contact  with  the  nerves 
that  they  would  have  the  same  action  as  when  carried  to  the  brain  through  the  circu- 
lation.    It  was  found  that  ether  and  chloroform  interrupted  the  conductivity  of  an 


I 


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METHODS  FOR   USING  LOCAL  ANESriIETICS  67 

exposed  nerve,  wlien  acting  npon  it,  in  the  fluid  or  gaseous  state  (Longet,  Bernstein, 
Kanke  and  others).  This  property  is  shared  by  many  other  non-anesthetic  substances 
as  the  function  of  a  nerve  is  dependent  upon  its  saturation  with  a  fluid  of  a  definite 
composition. 

Much  experimental  work  in  reference  to  chemical  stimuli  and  their  connection 
with  the  composition  of  chemical  compounds  is  being  undertaken  by  physiologists 
(Gruetzner).    These   studies  are  of  no  importance  to  local  anesthesia. 

Liebreich  and  his  pupils,  Bussenius,  Aluellerheim  and  Kunowski,  were  the  first 
to  systematically  experiment  with  a  number  of  organic  and  inorganic  compounds  in 
reference  to  their  local  anesthetic  properties.  Those  substances  not  already  fluid 
were  dissolved  and  injected  subcutaneously  or  placed  in  the  conjunctival  sac  of 
guinea-pigs,  rabbits  and  frogs.  Sensation  was  then  tested  by  pricking  wuth  needles, 
irritating  the  cornea,  or  by  using  Tuerck's  test.  The  subcutaneous  tissue  is  not  very 
suitable  for  such  experiments,  as  it  is  not  sufficiently  sensitive,  and  inasmuch  as  it  is 
not  situated  upon  the  surface  of  the  body  it  is  not  possible  to  determine  the  disturb- 
ance of  sensation  from  the  substance  injected,  but  only  that  of  the  overlying  skin. 
Notwithstanding  the  uncertainty  of  this  method  the  above-mentioned  authors  found 
that  by  far  the  most  of  the  anesthetic  or  non-anesthetic  substances  which  they 
tried  did  not  leave  sensation  intact,  but  were,  according  to  Liebreich,  "anesthetica 
dolorosa,"  that  is,  irritating  before  anesthetizing. 

The  number  of  the  anesthetica  dolorosa  are  found  to  be  more  numerous  when 
dilute  chemical  solutions  are  used  in  connection  with  the  Schleich  wheal  on  the  bodies 
of  persons  suitable  for  experimentation.  Only  after  we  knew  the  physiological  effect 
of  tumefaction  and  dehydration  and  the  determination  of  the  osmotic  pressure  of  the 
solutions  in  question  as  described  in  the  foregoing  chapter,  was  it  possible  to  place 
an  experimental  value  on  these  methods.  The  solution  must  have  a  freezing-point 
similar  to  that  of  blood,  due  either  to  the  active  substances  contained  in  it,  or  made 
so  by  the  addition  of  indiflferent  substances.  In  studying  the  differences  of  osmotic 
tension  between  the  tissue  fluids  and  the  injected  solutions,  we  have  already  deter- 
mined that  this  difference  alone  can  interrupt  sensation.  The  specific  action  of  a 
substance  dissolved  in  water  should  therefore  be  studied  when  the  solution  is  osmo- 
tically  indifferent.  With  the  aid  of  the  wheal  and  a  consideration  of  the  facts  just 
mentioned,  Heinze  and  the  author  found  that  there  were  few  chemically  indifferent, 
or  almost  indifferent,  compounds  which  upon  contact  with  the  sensory  elements  left 
sensation  intact.  Most  substances  are  active  but  only  a  few  of  these  are  able  to 
temporarily  influence  the  function  of  sensory  nerves  without  severe  irritation  and 
damage  to  the  tissues.  By  means  of  the  wheal  on  the  human  body  it  is  possi})le  to 
determine  relative  if  not  positive  values  as  to  the  local  anesthetic  properties  of  a 
substance. 


68  LOCAL  ANESTHESIA 

This  may  be  determined,  first,  by  finding  the  lowest  possible  concentration  of  a 
substance  in  solution  which  will  produce  a  local  anesthetic  effect.  This  is  done  by 
using  constantly  weaker  solutions,  making  allowance  for  the  difference  in  their  physical 
characteristics.  The  w^eaker  the  solution  the  greater  must  be  the  affinity  of  the  sub- 
stance for  the  protoplasm  of  the  tissue  cells,  that  is,  its  local  anesthetic  power.  All 
of  our  so-called  local  anesthetics  are  characterized  by  their  ability  to  influence  nerve 
substance  in  very  dilute  solution. 

The  second  means  at  our  disposal  for  the  approximate  determination  of  the  time 
of  occurrence  of  anesthesia  consists  in  producing  several  wheals  next  to  one  another 
upon  the  skin  of  the  person  to  be  experimented  upon  by  the  injection  of  the  same 
quantity  of  solutions  of  like  concentration,  that  is,  equimolecular  solutions.  The 
longer  the  duration  of  anesthesia,  the  more  lasting  must  be  the  changes  which  this 
agent  produces  on  the  nerve  substance.  The  duration  of  anesthesia  is  dependent 
upon  many  other  circumstances,  such  as  the  nature  of  the  person  experimented  upon, 
the  quantity  of  blood  in  the  part,  the  location  of  the  part  experimented  upon,  the 
rapidity  of  absorption,  and  the  concentration  of  the  solutions. 

On  the  plainly  visible  skin  wheals  other  tissue  changes  may  be  readily  noticed. 
For  instance,  it  can  })e  readily  determined  whether  the  wheal  disappears  rapidly 
and  completely,  showing  that  the  substance  was  absorbed  without  local  tissue  damage, 
or  whether  painful  infiltrates  remain  which  may  undergo  inflammation  or  necrosis, 
or  whether  the  bloodvessels  dilate  or  contract.  Following  experiments  with  codeine, 
morphine,  peronin,  and  tropacocain  upon  the  skin,  an  acute  local  edema  occurs 
resembling  that  of  insect  poisoning.  In  this  manner  substances  can  readily  be  tested 
and  compared  in  their  action  with  other  substances  without  danger  to  the  individual 
experimented  upon,  provided  very  dilute  solutions  are  used  at  the  start.  The  results 
of  such  investigations  can  be  at  once  put  to  practical  use.  When  the  solution  of  a 
substance  is  not  brought  into  immediate  contact  with  nerve  elements  by  injection 
but  reaches  it  indirectly  by  diffusion,  then  the  local  anesthetic  effect  cannot  be  deter- 
mined alone  by  the  above-mentioned  experiments,  but  will  depend  upon  this  per- 
meability of  the  membranes  with  which  it  comes  in  contact,  and  the  diftusibility  of 
the  substance.  Thus  a  substance  having  pronounced  anesthetic  properties  may  be- 
come useless  because  unable  to  diffuse  through  a  membrane  or  layer  of  tissue  and 
reach  the  nerve  elements.  Cocain,  having  marked  local  anesthetic  properties,  is 
ineffective  when  placed  upon  the  skin,  as  it  cannot  penetrate  it  while  a  similar  appli- 
cation of  dilute  solutions  of  carbolic  acid  which  have  only  slight  anesthetic  properties 
cause  a  marked  diminution  of  sensation.  A  comparison  of  various  substances  pre- 
viously shown  to  be  harmless  can  be  obtained  by  observing  the  extent  of  anesthesia 
as  affected  by  the  process  of  diffusion,  if  solutions  of  like  strength  be  injected  into  the 
subcutaneous  cellular  tissue  in  the  region  of  the  nerves  of  the  skin,  and  noting  the 


METHODS  FOR   USING  LOCAL  ANESTHETICS  69 

duration  and  extent  of  the  anesthesia  in  the  area  of  (Hstribution  of  these  nerves. 
Recke  has  taken  up  the  very  important  comparative  study  of  the  newer  substitutes 
for  cocain  along  the  lines  mentioned  above;  the  results  of  his  work  will  be  referred 
to  later.  Gradenwitz  has  determined  the  relati^'e  values  of  the  local  anesthetic 
power  of  chemical  compounds  in  their  actions  on  the  skin  of  a  frog.  His  method  of 
procedure  was  as  follows:  the  brain,  medulla  oblongata,  and  heart  were  removed 
from  frogs,  the  blood  was  washed  from  the  vessels,  the  object  being  to  prevent  the 
general  absorption  of  the  substances  and  thus  isolate  their  local  action.  The  solution 
to  be  tested  was  brushed  upon  the  left  leg  of  the  frog,  and  after  being  allowed  to  act 
for  a  definite  length  of  time  was  washed  oflf.  Both  legs  were  then  immersed  in  a 
I  per  cent,  hydrochloric  acid  solution,  according  to  the  direction  of  Tuerck,  and 
the  condition  of  the  reflexes  tested.  Four  distinct  phenomena  were  recognized: 
(1)  Both  legs  were  simultaneously  drawn  up;  the  substance  was  ineffective.  (2) 
After  a  short  time  the  left  leg  was  drawn  up;  the  substance  had  increased  the  sensi- 
bility. (3)  The  right  leg  was  drawn  up  sooner  than  the  left;  the  sensibility  of  the 
left  leg  was  diminished.  (4)  The  left  leg  was  not  drawn  up;  sensation  was  absent. 
This  last  experiment  was  controlled  by  immersing  the  legs  in  a  25  per  cent,  hydro- 
cliloric  acid  solution. 

The  results  of  the  investigations  of  Gradenwitz  apply  only  to  the  skin  of  the  frog, 
the  physiological  properties  of  which  must  materially  influence  the  local  action  of  the 
substance.  It  was  particularly  noticeable  that  stimulation  of  any  sort  was  practi- 
cally never  observed  even  with  substances  which,  according  to  the  investigations  of 
the  pupils  of  Liebreich  and  the  writer,  must  be  classed  as  anesthetica  dolorosa.  The 
practical  application  of  the  observations  of  Gradenwitz  and  a  comparison  of  their 
value  with  other  methods  of  investigation  is  not  possible  so  long  as  the  permeability 
of  frogs'  skin  for  various  substances  is  unknown. 

A  different  sort  of  animal  experimentation  was  advised  by  Loewy  and  Mueller 
for  the  testing  of  yohimbin,  a  supposed  new  anesthetic.  If  animals  are  allowed  to 
inhale  vapor  of  ammonia,  expiratory  paralysis  at  once  takes  place,  due  to  irritation 
of  the  trigeminus  fibers  in  the  nasal  mucosa.  If  the  nasal  mucosa  is  previously  anes- 
thetized, the  action  of  the  ammonia  is  diminished,  that  is,  respiration  becomes  slower, 
more  superficial,  or  may  cease.  To  those  who  have  had  experience  in  animal  experi- 
mentation the  difficulties  of  obtaining  exact  results  in  testing  sensation  is  well  known 
the  results  are  only  of  approximate  value. 

Important  results,  to  which  we  will  repeatedly  refer,  have  been  obtained  through 
the  researches  of  Laewen  and  Gross.  They  allowed  the  anesthetizing  solutions  to  act 
directly  upon  the  sciatic  nerve  of  frogs  and,  after  observing  their  effect  upon  the  motor 
excitability  of  the  nerve,  compared  results  with  those  obtained  in  the  tumefaction 
experiments. 


70  LOCAL  ANESTHESIA 

It  has  been  shown  that  the  anesthetic  property  of  various  chemical  compounds 
is  associated  with  certain  groups  of  atoms  inherent  in  the  molecule,  which  Ehrlich 
has  termed  the  anesthesiphore.  The  other  groups  of  atoms  can  be  readily  replaced 
in  the  construction  of  new  anesthetic  substances.  Experiments  along  these  same 
lines  resulted  later  in  the  discovery  of  salvarsan  by  Ehrlich.  After  the  discovery 
of  the  chemical  composition  of  cocain  with  its  atomic  grouping  by  Einhorn,  the 
synthetic  preparation  of  this  alkaloid  became  possible  and  served  as  a  starting-point 
for  interesting  experiments  in  combining  the  anesthesiphore  atomic  group  with  new 
atomic  groups.  This  chemical  research  resulted  in  the  discovery  of  a  number  of  new 
local  anesthetics,  such  as  holocain,  eucain,  and  those  of  the  orthoform  group;  later 
stovain,  alypin,  and  novocain — certainly  a  triumph  of  an  exact  science.  In  regard 
to  the  chemical  relation  of  these  substances  to  one  another,  the  reader  is  referred 
to  Einhorn 's  comprehensive  compilation. 

The  previously  discovered  practical  local  anesthetic  substances  have  the  following 
properties  in  common.  They  are  all  protoplasmic  poisons,  paralyzing  not  only  the 
nerve  elements  but  the  function  of  all  protoplasm  with  which  they  come  in  active 
contact.  This  action  they  possess  in  common  with  many  other  active  substances, 
even  with  the  physical  action  of  water  upon  the  protoplasm.  Their  intense  selective 
affinity  for  nerve  substance  is  particularly  characteristic.  They  paralyze  the  function 
of  nerve  tissues  with  which  they  come  in  active  contact  in  solutions  too  weak  to 
appreciably  influence  other  kinds  of  protoplasm.  These  substances,  when  introduced 
rapidly  and  in  sufficient  quantity  into  the  circulation,  besides  their  local  eflFect,  pro- 
duce general  symptoms  of  poisoning.  The  affinity  of  these  substances  for  nervous 
tissue  makes  them  particularly  toxic  to  the  central  nervous  system. 

It  is  of  practical  importance  to  remember  that  these  secondary  symptoms  are  not 
dependent  upon  the  dose  used,  as  local  anesthetic  substances  have  no  so-called 
maximum  dosage,  but  rather  upon  the  rapidity  with  which  they  are  introduced  into 
the  body  and  absorbed  from  the  same.  This  will  be  discussed  more  in  detail  in  the 
following  chapter  on  cocain. 

Local  anesthetics  are  characterized  by  their  reversibility  of  action.  They  are  able 
to  temporarily  interrupt  nerve  function  without  any  permanent  injury  remain- 
ing, being  thus  distinguished  from  Liebreich's  anesthetica  dolorosa  which  cause 
irritation  before  paralysis,   followed  by  injury  to  the   tissues. 

Gross  summarized  the  above-mentioned  experiments  regarding  the  general  prop- 
erties of  local  anesthetics  in  the  following  manner:  The  base  of  local  anesthetics 
(cocain,  novocain,  stovain,  eucain  and  alypin)  all  have  a  more  intense  action  than 
their  salts,  for  the  reason  that  the  basic  local  anesthetics  acted  more  quickly  and 
in  weaker  solutions  than  their  salts.  The  anesthetic  potential  of  a  local  anesthetic 
salt  is  dependent  upon  the  anesthetic  potential  of  the  base  and  upon  the  hydrolytic 


METHODS  FOR   i'SING  LOCAL  ANESTHETICS  71 

dissociation  of  the  solution.  The  (lifl'erence  in  action  of  sohitions  containinj,^  the 
chloride  salts  of  the  local  anesthetics  in  general  use  is  shown  to  be  dependent  upon 
the  (degree  of  hydrolytic  dissociations  of  the  solutions.  The  weaker  the  salt-forming 
{)o\ver  of  an  acid  the  greater  the  hydrolytic  dissociation  of  the  solution;  thus  the  activ- 
ity of  a  solution  of  a  local  anesthetic  salt  is  greater  the  weaker  its  acid  radical;  for 
example,  a  novocain-bicarbonate  solution  is  five  times  as  active  as  an  equimolecular 
novocain-chloride  solution.  The  sensory  nerves  as  will  be  shown  with  cocain 
(see  page  87)  are  more  sensitive  to  the  action  of  local  anesthetics  than  the  motor 
nerves. 

Following  the  experiments  of  jNIeyer  and  Overton  on  anesthesia,  Gross  attempted 
to  explain  the  processes  underlying  anesthetic  action.  They  maintain  that  anesthetics 
act  upon  the  lipoid  substance  of  the  central  nervous  system.  Anesthesia,  therefore, 
depends  upon  the  fat-dissolving  power  of  the  drug;  the  more  powerful  the  anesthetic 
the  greater  is  its  ability  to  dissolve  fat,  so-called  splitting  coefficient — that  is,  the  rela- 
tion between  their  fat-dissolving  power  and  their  w^ater-dissolving  power.  In  con- 
sequence of  their  strong  solvent  action  on  fat,  anesthetics  accumulate  in  the  central 
nervous  system  where,  according  to  Meyer  and  Overton,  they  do  not  enter  into  chem- 
ical combination,  but  only  bring  about  a  physical  change  in  the  lipoids,  forming  a 
fixed  solution,  as  it  were.  According  to  Gross  this  theory  has  a  corresponding  value 
for  the  action  of  local  anesthetics  on  the  peripheral  nervous  system. 

Verworn,  Buerker,  and  others,  though  not  denying  the  theory  of  Meyer  and  OAcrton 
regarding  the  relation  of  anesthetics  to  the  lipoids,  nevertheless  hold  to  the  older 
theory  that  anesthetic  action  is  due  to  the  formation  of  chemical  compounds  in  the 
central  nervous  system.  Both  maintain  that  anesthetics  act  by  depriving  nerve 
substance  of  oxygen,  causing  a  temporary  suffocation,  combined  with  paralysis  of 
their  physiological  function.  The  fact  that  a  portion  of  the  anesthetic  remains  at  the 
place  of  application  and  does  not  enter  the  circulation  before  being  destroyed,  seems 
to  favor  the  chemical  theor}',  at  least  for  local  anesthetics.  Leaving  out  of  consid- 
eration the  finer  changes  in  nerve  tissue  resulting  from  general  and  local  anesthesia, 
without  detracting  from  our  present  knowledge  we  may  mention  the  older  theory  of 
Preyer,  who  stated  that  general  and  local  anesthetics  produce  changes  in  the  central 
nervous  system  and  peripheral  nerves,  causing  a  temporary  loss  of  function  of  the 
cells,  for  the  restoration  of  which  their  entire  vital  energy  is  necessary. 

Before  taking  up  for  consideration  the  various  local  anesthetic  agents  it  is  important 
for  us  to  know  in  what  way  their  application  produces  terminal  and  conduction 
anesthesia  in  man. 

The  schematic  cross-section  (as  shown  in  Fig.  5)  represents  the  surface  of  any  part 
of  the  body;  the  line  A-B  representing  skin,  mucous  membrane,  serous  membrane, 
or  synovial  membrane,  on  the  surface  of  the  body,  or  lining  one  of  its  cavities.     iVi 


72  LOCAL  ANESTHESIA 

and  iV2  represent  two  sensory  nerve  trunks  ramifying  in  the  tissues,  and  as  usual  over- 
lapping one  another  in  their  area  of  distribution,  so  that  a  certain  area  is  innervated 
by  the  terminal  branches  of  several  nerves.  We  shall  now  attempt  to  anesthetize 
the  circular  area  marked  I  with  an  active  anesthetic  substance.  Area  /  can  be  ren- 
dered insensitive  by  bringing  the  sensory  endings  in  contact  with  a  sufficient  quantity 
of  an  anesthetic  which  will  inhibit  their  function.  This  is  called  terminal  anesthesia 
and  can  be  brought  about  in  several  ways. 


Am 


N/       Nz 


Fig.  5. — Schematic  diagram  of  the  methods  of  local  anesthesia. 

1.  A  solution  of  an  active  substance  is  injected  into  the  tissues  under  slight  pres- 
sure, so  that  area  I  is  thoroughly  saturated  with  the  solution,  replacing  the  normal 
tissue  fluids.  The  molecules  of  the  dissolved  substance,  mechanically  injected, 
immediately  come  in  contact  with  the  tissue  elements  and  promptly  give  evidence 
of  their  uniform  action  in  the  entire  area.  A  chemical  action  will  also  be  observed 
when  the  solution  is  diluted  to  the  lowest  limit  of  activity  of  the  dissolved  substance; 
this  type  of  infiltration  is  seen  in  the  skin  wheal  and  has  been  designated  by  Schleich 
as  infiltration  anesthesia.  The  duration  and  intensity  of  this  anesthesia  is  in  propor- 
tion to  the  change  produced  in  the  nerve  substance  and  the  strength  of  the  solution. 
The  more  concentrated  the  solution  the  longer  the  duration  of  the  anesthesia.  The 
duration  and  intensity  of  the  anesthesia  is  the  same  in  the  entire  area,  as  the  nerve 
elements  have  been  equally  afi'ected. 

2.  In  the  area  designated  in  the  figure  by  /,  other  methods  can  be  employed  for 
producing  terminal  anesthesia.  If  an  anesthetic  solution  be  injected  in  the  centre 
of  the  area  represented  by  II  in  the  diagram  the  same  local  conditions  will  occur 
in  this  area  as  have  been  mentioned  for  infiltration  anesthesia.    Whether  the  solution 


METHODS   FOR    iSJXG   LOCAL   ANESTHETICS  73 

has  the  same  or  ditiVrcnt  osmotic  i)ressiire  than  the  blood,  there  now  takes  phice 
an  exchange  of  molecules  between  the  dissolved  substance  and  the  salts  in  the  tissue 
fluids.  The  former  diffuse  with  more  or  less  rapidity,  depending  upon  their  diffusi- 
bility,  the  permeability  of  the  membranes  surrounding  the  area,  and  the  concentra- 
tion of  the  solution,  affecting  the  tissues  after  a  certain  time  in  the  entire  area  des- 
ignated in  the  diagram  by  I,  producing  the  same  symptoms  as  originally  took  place 
in  the  centre  of  the  area  designated  by  II.  A  difference  nevertheless  exists,  as  the 
solution  during  the  process  of  diffusion  becomes  constantly  more  dilute,  containing 
less  of  the  active  substance  owing  to  portions  of  it  being  combined  with  the  tissues 
the  farther  it  is  removed  from  the  place  of  injection.  In  consequence  of  which  in 
a  given  case  the  intensity  of  anesthesia  will  diminish  from  centre  toward  the  periph- 
ery in  the  area  marked  I  in  the  diagram.  The  action  by  diffusion  of  a  substance 
can  scarcely  be  expected  if  the  solution  is  so  dilute  that  the  dissolved  substance  is 
only  sufficient  for  producing  anesthesia  in  the  area  infiltrated,  the  number  of  mole- 
cules capable  of  diffusion  into  the  surrounding  tissues  being  too  small  to  be  effective. 
It  is  therefore  necessary  that  small  quantities  of  a  concentrated  solution  be  used  to 
produce  in  this  manner  a  local  anesthetic  effect,  the  same  as  though  the  entire  area 
designated  I  had  been  infiltrated.    This  is  the  so-called  indirect  infiltration  anesthesia. 

An  anesthetic  solution  when  placed  upon  the  surface  A-B  can,  by  means  of  diffusion, 
reach  the  nerves  in  the  area  designated  I.  Local  anesthetic  action  can,  however,  only 
occur  when  the  protecting  membrane  is  permeable  to  the  solution,  and  the  solution 
much  more  concentrated  than  that  used  for  injection. 

Local  anesthetics  can  affect  the  function  and  conductivity  of  nerve  trunks  at  points 
remote  from  their  area  of  distribution,  as  when  solutions  are  injected  in  the  region 
of  the  nerve  trunks  III  and  IV  supplying  area  7.  By  means  of  diffusion  their  con- 
duction will  be  interrupted,  causing  the  so-called  conduction  anesthesia  in  this  area. 
With  the  use  of  very  weak  solutions  the  nerve  must  be  injected  directly,  diffusion 
under  these  circumstances  being  insufficient  to  interrupt  conduction.  Results  of 
diffusion  require  waiting  a  certain  time  for  anesthetic  action. 

If  an  anesthetic  substance  be  injected  into  an  artery  or  vein  the  circulation  in 
which  has  been  interrupted,  terminal  and  conduction  anesthesia  will  occur  in  the 
area  of  distribution  of  the  respective  vessels  (arterial  and  venous  anesthesia). 


CHAPTER   VII. 

LOCAL  ANESTHETIC  AGENTS. 

Local  anesthesia  received  its  greatest  impetus  following  the  discovery  of  sub- 
stances of  specific  activity.  From  ancient  literature  we  learn  of  the  attempts  which 
were  made  to  produce  local  anesthesia  by  various  drugs,  which  remained,  however, 
without  results  until  appropriate  agents  were  discovered.  The  oldest  of  these,  and  for 
years  the  only  local  anesthetic,  was  the  alkaloid  cocaine,  derived  from  the  cocoa 
plant.  Its  properties  have  been  carefully  studied,  and  inasmuch  as  these  are  typical 
of  all  local  anesthetics,  we  will  devote  more  time  to  it  than  to  its  substitutes,  even 
though  these  have  detracted  in  great  measure  from  the  parent  drug. 


The  coca  plant  (Erythroxylon  coca  Lam.)  is  indigenous  to  Peru  and  Bolivia, 
has  been  cultivated  since  prehistoric  times,  and  been  prominent  in  the  religious 
and  political  life  of  the  people.  This  plant  was  regarded  as  a  gift  of  God  which 
"satiated  the  hungry,  gave  renewed  energy  to  the  tired  and  weary,  and  caused  the 
unfortunate  to  forget  sorrows"  (Novinny).  During  the  reign  of  the  Incas  only  the 
royal  families  had  the  right  to  cultivate  the  coca  plant  and  to  enjoy  its  consump- 
tion. Francisco  Pizarro,  in  1532,  while  exploring  the  interior  of  Peru,  found  the  coca 
lea\'es  widely  distributed  and  their  use  much  abused.  Under  Spanish  regime  the  cul- 
tivation of  the  coca  plant  was  at  first  prohibited,  later  monopolized  by  the  govern- 
ment, and  finally  the  people  were  again  accorded  the  privilege  of  cultivating  the  plant, 
which  was,  however,  subject  to  taxation.  According  to  Wedell,  in  Bolivia  alone,  in 
1850,  three  million  Spanish  dollars  were  collected  as  a  revenue  from  this  plant.  The 
interest  of  the  scientific  world  w^as  first  aroused  by  the  reports  of  travellers,  as  Tschudi 
and  Poeppig,  according  to  w^hom  the  coca  leaves  were  chewed  by  the  natives  of  South 
America  in  order  to  alleviate  hunger,  to  produce  wakefulness,  and  increase  their 
physical  powers  of  endurance.  The  continued  and  excessive  use  of  the  coca  leaves 
ultimately  resulted  in  a  shattered  nervous  system.  The  natives  still  feel  the  necessity 
of  the  coca  leaf  when  undertaking  work  which  requires  great  physical  effort.  The 
green  leaves  when  mature,  are  picked,  dried  in  the  sun,  and  immediately  packed. 


LOCAL  ANESTHETIC  AGENTS  75 

Scherzer  was  tlie  first  to  bring  a  large  (luantity  of  these  leaves  to  Europe;  later 
AYoehler.  of  (Tottiiigen,  received  some  of  these  leaves  and  from  them  his  pupils, 
Xiemaiui  and  Lossen,  extracted  cocain.  Cocain  was  later  synthetically  prepared 
by   Merck,  Skraup,  Einhorn,  Liebermann  and  (liesel. 

Cocain  (C17H21XO4)  crystallizes  in  large  four-  to  six-sided  colorless  prisms.  It  is 
sparingly  soluble  in  water,  but  dissolves  readily  in  alcohol,  ether,  and  ethyl  chloride. 
It  has  a  bitter  taste  and  is  of  alkaline  reaction.  It  melts  at  98°  C,  being  decomposed 
and  con^•erted  into  ecgonin.  It  combines  readily  with  the  acids  to  form  salts,  of 
which  the  hydrochloride  is  the  best  known  and  most  frecjuently  used  therapeutically. 
Cocain  hydrochloride  (C17H21XO4  HCl)  is  a  white  crystalline  powder,  readily  soluble 
in  water  and  alcohol,  and  when  placed  upon  the  tongue  has  a  bitter  taste.  For  the 
sake  of  brevity  the  term  cocain  will  be  used  to  denote  cocain  hydrochloride  in 
the  following  paragraphs. 

History  of  Cocain  Anesthesia  and  Cocain  Poisoning. — The  discoNcry  of  the  local 
anesthetic  properties  of  cocain  gave  a  new  impetus  to  local  anesthesia,  its 
history  for  more  than  twenty  years  being  practically  identical  with  that  of 
cocain  anesthesia.  Substitutes  for  cocain  have  only  been  known  in  late  years. 
The  first  reports  regarding  the  anesthetic  properties  of  cocain  were  made  by 
Scherzer,  who  noticed  that  the  chewing  of  coca  lea^'es  caused  a  feeling  of  numbness 
in  the  tongue.  The  same  properties  were  obser^-ed  from  the  use  of  erythroxylin 
prepared  from  coca  leaves  by  Garnicke  (1855)  and  Percy  (1857),  and  in  a  more 
l)ronounced  manner  from  cocain  itself.  (Niemann  1860,  Demarle,  Schroff  18G2, 
^Moreno  y  INIaiz  1868,  von  Anrep  1879).  Von  Anrep  investigated  the  local  action 
of  this  new  remedy  upon  the  skin  and  conjunctiva.  He  injected  a  weak  solution  of 
cocain  under  the  skin  of  his  arm.  There  was  at  first  a  feeling  of  warmth,  then  loss 
of  sensation  to  the  prick  of  a  needle  at  the  point  of  injection.  In  about  fifteen  minutes 
the  skin  injected  became  red,  which,  after  the  lapse  of  twenty-five  to  thirty  minutes, 
disappeared  together  with  the  previously  mentioned  symptoms.  Upon  instilling 
a  solution  of  cocain  into  the  conjunctival  sack  of  animals  he  noticed  only  the  pre- 
viously well-known  mydriatic  action  of  the  drug.  On  the  other  hand,  Coupard  and 
Borderau,  in  1880,  made  positive  observations  as  to  the  loss  of  corneal  reflex  in  ani- 
mals following  the  use  of  solutions  of  cocain.  Fauvel,  Saglia,  and  others  had  already 
learned  to  use  coca  leaves  and  their  extracts  in  the  treatment  of  painful  affections 
of  the  larynx  and  pharynx.  This  was  the  situation  when  Koller,  and  shortly  there- 
after Koenigstein,  demonstrated  that  by  the  instillation  of  a  2  per  cent,  cocain 
solution,  the  eye  could  be  made  sufficiently  insensiti^'e  to  carry  out  many  opera- 
tions without  pain.  Koller  reported  his  observations  on  this  subject  at  the  Ophthalmo- 
logical  Congress  held  in  Heidelberg  in  1884,  his  results  being  soon  affirmed  by  Agnew, 
Moore,  Elinor,  Knapp,  Hirschberg,  Graefe,  Abadie,  Panas,  Trousseau  and  Horner. 


76  LOCAL  ANESTHESIA 

Rapidly  following  upon  these  reports  the  use  of  cocain  upon  the  eye  and  its  mucous 
membranes  was  universally  accepted  and  put  to  practical  use  in  all  operations  on  the 
eye.  In  the  same  year  cocain  was  extensively  used  in  laryngology  (Jellinek,  Schroet- 
ter,  Stoerk,  Zaufel,  Fauvel)  and  rhinology  (Bosworth,  Lublinski).  Otis  and  Knapp 
used  this  method  of  anesthesia  upon  the  mucous  membrane  of  the  male  urethra, 
while  Fraenkel  carried  out  similar  experiments  upon  the  female  genitalia.  This  new 
discovery  was  of  great  value  to  ophthalmology,  as  many  eye  operations  could  be  more 
exactly  performed  than  with  general  anesthesia.  It  was  of  like  importance  in  laryn- 
gology^ and  rhinolog}',  where  operations  previously  impossible  could  now  be  carried 
out.  Schroetter,  who  at  first  was  skeptical  regarding  the  experiences  of  his  pupil, 
Jellinek,  shortly  thereafter  made  the  following  statement:  "One  may  now  say  that 
the  technical  difhculties  of  operating  upon  the  larynx  have  been  overcome  and  that 
laryngeal  surgery  can  now  be  generally  practised  by  all  physicians."  The  present 
perfection  of  technique  in  laryngology  and  rhinology  is  inconceivable  without  an 
agent  like  cocain,  which  not  alone  allays  pain  and  inhibits  reflexes  but  likewise 
causes  a  contraction  of  the  mucous  membrane,  so  that  the  larynx  and  nasal  cavities 
become  easily  accessible. 

By  means  of  injections  of  solutions  of  cocain  into  the  tissues,  this  form  of  anes- 
thesia became  applicable  in  surgery  and  dentistry.  At  first  very  concentrated  solu- 
tions were  used  (2  to  20  per  cent.),  a  few  drops  of  which  injected  into  the  subcutaneous 
connective  tissue  produced  in  a  short  time,  by  diffusion  of  this  agent,  anesthesia, 
not  only  of  the  overlying  skin  but  also  of  the  deeper  fascia,  a  fact  long  recognized 
by  Anrep.  By  means  of  a  number  of  such  injections  made  near  one  another,  large 
areas  could  be  anesthetized,  a  method  formerly  in  use  by  Corning,  Roberts, 
Landerer,  Woelfler,  Dujardin-Beaumetz,  Verchere,  Hall,  Witzel  and  others.  An 
observation  of  great  importance  w^as  made  by  Corning,  in  1885,  who  reported  that 
by  interrupting  the  circulation  better  anesthetic  effects  could  be  obtained  by  the  use 
of  dilute  solutions  (0.25  to  0.33  per  cent.),  and  without  the  danger  of  poisoning,  than 
had  formerly  been  obtained  with  more  concentrated  solutions  where  the  circulation 
was  not  interrupted.  For  the  purpose  of  interrupting  the  circulation  in  the  extremities 
he  used  the  Esmarch  bandage;  for  other  parts  he  constructed  clamps  and  wire  rings 
covered  with  rubber  which  were  pressed  upon  the  skin.  He  placed  special  stress 
upon  the  necessity  of  injecting  the  cocain  solution  before  interrupting  the  circula- 
tion. By  the  aid  of  this  method  Roberts  was  able  to  perform  a  partial  resection  of 
the  elbow  (cocain  used  0.06),  and  later  an  osteotomy  of  the  femur  for  genu  valgum 
(cocain  used  0.19)  without  pain.  He  made  the  observation  at  this  time  that  after 
the  injection  of  cocain  beneath  the  periosteum  the  latter  could  be  separated  from 
the  bone  and  the  bone  itself  divided  without  pain.  Conway  used  this  same  method 
in  anesthetizing  fractures  for  the  purpose  of  reduction.    Anesthesia  of  a  hydrocele 


LOCAL  ANESTHETIC  AGENTS  77 

sac  by  means  of  cocaiii  injections  ^vas  performed  by  Biirdel,  Thiery,  and  others. 
In  the  year  1887,  thanks  to  the  efforts  of  Woelfler,  a  hirge  number  of  reports  were 
collected  regarding  operations  carried  out  under  cocain  anesthesia  (Schustler, 
Fraenkel,  Spitzer,  Chiari,  von  Fillenbaum,  Lustgarten,  Frey,  Hoffman,  Fux,  Hoch- 
stctter,  Orloft"  and  others).  Cocain  anesthesia  was  used  in  all  branches  of  surgery 
and  was  not  limited  to  minor  operations.  Amputations  of  the  leg,  tracheotomies, 
extirpation  of  large  tumors,  herniotomies,  and  abdominal  operations  of  all  sorts  were 
attemy)ted  with  more  or  less  success.  Many  surgeons  (Woelfier,  Fraenkel,  Orloff) 
emphasized  the  necessity  of  infiltrating  thoroughly  the  entire  area  to  be  operated 
upon  with  the  anesthetic  solution  rather  than  depend  upon  its  diffusion  if  one  desired 
to  anesthetize  the  tissues  with  certainty.  Roberts,  in  1885,  described  his  method  of 
saturating  the  skin  with  cocain  solution;  he  made  superficial  injections  in  the  pro- 
posed line  of  incision,  followed  this  by  a  subsequent  injection  at  the  periphery  of  the 
anemic  zone  produced  by  the  first  injection,  continuing  thus  until  the  entire  operative 
field  was  made  insensitive;  the  deeper  parts  were  anesthetized  in  a  similar  manner. 
The  systematic  development  of  this  method,  which  is  known  today  as  Schleich's 
infiltration  anesthesia,  was  made  by  Reclus  and  Schleich.  The  properties  of  this 
new  agent  were  utilized  in  many  ways  outside  of  the  field  of  surgery.  The  observa- 
tions of  Corning  and  Goldscheider,  made  on  both  animals  and  man,  that  the  conduc- 
tivity of  nerve  trunks  could  be  interrupted  by  cocain  solutions,  with  the  result  that 
the  area  innervated  by  these  nerves  became  anesthetic,  was  put  to  practical  use  by 
Halstead,  in  1885,  in  the  extraction  of  teeth.  In  this  operation  cocain  was  not  injected 
around  the  tooth  to  be  extracted  but  into  the  trunk  of  the  infraorbital  nerve,  the 
injection  being  made  from  wdthin  the  mouth.  Later  by  means  of  a  similar  method 
Kummer  and  Pernice  w^ere  able  to  amputate  fingers  and  toes  (Oberst) .  A  very  impor- 
tant contribution  to  the  literature  w^as  made  by  Corning  in  1885;  he  injected  a  2  to 
3  per  cent,  cocain  solution  between  the  spinous  processes  of  the  lower  dorsal  vertebrae 
into  the  spinal  canal  and  noted  the  occurrence  of  anesthesia  in  the  lower  extremities 
from  the  effect  of  this  agent  upon  the  cord.  Only  in  recent  years  has  this  so-called 
anesthesia  of  the  cord  become  of  practical  value.  We  can  only  briefly  mention  that 
in  1886  Wagner  and  Herzog  used  the  cataphoric  action  of  the  galvanic  current  in 
attempts  to  make  the  unbroken  skin  anesthetic,  it  being  well  known  that  cocain 
solutions  alone  could  not  penetrate  this  structure.  Thus  in  a  short  time  local  anes- 
thesia by  means  of  cocain  solutions  was  attempted  in  all  possible  ways,  but  the 
enthusiasm  attendant  upon  the  efforts  made  to  replace  general  anesthesia  by  local 
anesthesia  was  destined  to  suffer  the  disappointments  consequent  upon  its  unre- 
stricted use. 

The  first  objection  against  the  general  use  of  local  anesthesia  was  given  expression 
by  Hoffman  and  Fraenkel.    The  association  of  unconsciousness  with  general  anesthesia 


78  LOCAL  ANESTHESIA 

became  so  fixed  in  tlie  minds  of  the  people  that  it  was  not  readily  controverted, 
or,  as  Fraenkel  stated,  most  people  desire  to  pass  unconsciously  the  serious  crisis 
associated  with  every  operation.  The  second  and  more  serious  objection  at  that 
time  was  the  great  danger  associated  with  cocain  anesthesia.  Attempts  were  made 
in  vain  to  counteract  these  serious  consequences  by  the  use  of  remedies  known  to  be 
of  value  for  other  poisons  and  the  determination  of  the  maximum  doses.  Too  little 
attention  was  paid  to  the  warning  of  Corning  who  stated:  "A  remedy  which  has  such 
a  strong  chemical  affinity  for  nerve  substance  must  also  affect  the  heart  and  central 
nervous  system  when  introduced  into  the  circulation  in  concentrated  solution." 

]\Iild,  severe,  and  fatal  cases  of  cocain  poisoning  have  been  observed  in  great 
numbers  following  the  use  of  this  drug  internally  and  subcutaneously,  and  by  local 
application  to  mucous  membranes,  but  most  frequently,  of  course,  when  used  for  sur- 
gical purposes.  A  compilation  of  the  published  cases  of  cocain  poisoning  was  made 
by  Falk  and  later  by  Weigand.  These  cases  naturally  represent  but  a  small 
part  of  the  entire  number  obser\'ed.  These  statistics  were  lacking  in  exactness, 
inasmuch  as  the  strength  of  the  solution  used  was  not  mentioned;  nevertheless, 
if  one  may  judge  from  the  tendencies  of  the  times,  concentrated  solutions  were  used. 
A  distinction  must  be  made  between  those  cases  in  which  cocain  is  introduced 
directly  into  the  body  and  entirely  absorbed,  as  in  the  internal  administration  or  in- 
jections into  the  tissues,  and  those  cases  in  which  only  a  portion  of  the  quantity  used 
is  absorbed,  as  in  anesthetizing  mucous  and  serous  membranes.  In  the  latter  case 
the  size  of  the  absorbing  surface  to  which  the  cocain  is  applied  is  of  great  importance. 
Ophthalmologists  who  use  cocain  very  frequently  seldom  have  cases  of  poisoning; 
among  Weigand's  26  cases  there  was  not  one  fatality.  The  cause  of  death  in  the 
case  reported  by  Bottard  (La  Normandie  med.,  1887,  cited  by  Huber)  following 
the  instillation  of  a  2  per  cent,  cocain  solution  into  the  eye,  must  be  considered 
questionable,  as  the  strength  of  the  solution  is  seldom  more  than  2  to  4  per  cent, 
and  the  extent  of  the  mucous  membrane  treated  is  very  small.  In  17  cases 
of  poisoning  following  the  application  of  cocain  to  the  nasal  mucosa  Weigand 
reports  no  death;  in  12  cases  of  poisoning  following  applications  to  the  mouth  and 
pharynx  there  were  two  deaths;  in  11  cases  of  poisoning  after  applications  to  the  larynx 
there  was  one  death.  Three  deaths  are  noted  following  the  application  of  cocain 
to  the  rectal  mucous  membrane,  two  of  which  no  doubt  refer  to  one  and  the  same 
patient  whose  death  caused  the  unfortunate  surgeon,  Kolomnin,  to  commit  suicide. 
The  use  of  cocain  solutions  of  from  2  to  10  per  cent,  is  particularly  dangerous  in 
closed  cavities  lined  with  mucous  or  serous  membranes,  such  as  the  urethra,  bladder, 
and  scrotal  cavity.  In  the  24  cases  collected  by  Weigand  there  were  many  very 
severe  cases  of  poisoning,  with  three  deaths  (Sims,  0.8  cocain,  concentration  not 
given;    Reclus,  1.0  cocain  in  5  per  cent,  solution;    Pfister,  1.0  cocain  in  20  per  cent. 


LOCAL  ANESTHETIC  AGENTS  79 

solution).  In  a  later  case  r(.'i)orte(l  hy  Czerny,  death  followed  an  injection  of  7  e.c.  of 
a  1  per  cent,  eocain  solution  into  the  urethra.  Two  similar  but  unpublished  cases  were 
reported  to  the  author  personally  where  death  followed  the  injection  of  several  cubic 
centimeters  of  a  5  per  cent,  eocain  solution  into  the  bladder.  Berger  reports  a  case 
in  which  exitus  lethalis  followed  the  injection  of  about  0.35  eocain  in  2  per  cent,  solu- 
tion into  the  scrotal  sac.  A  similar  death  occurred  in  1905  after  Prouardel  injected 
40  c.c.  of  a  5  per  cent,  solution  of  eocain  into  the  scrotal  sac,  although  the  solution 
was  allowed  to  drain  out  after  three  to  four  minutes.  The  num})er  of  deaths  which 
actually  occurred  in  this  manner  is  certainly  greater  than  the  lumiber  reported, 
for  which  reason  we  must  conclude  that  the  application  of  strong  eocain  solutions 
to  large  absorbent  surfaces  is  dangerous  and  not  to  be  recommended.  Weigand 
reports  15  cases  of  eocain  poisoning  with  4  deaths,  the  eocain  being  administered 
by  the  mouth,  the  quantity  varying  from  0.8  to  1.5.  There  have  been  132  cases 
of  poisoning  reported  following  the  hypodermic  injection  of  eocain,  with  8  deaths; 
this  does  not  include  the  cases  already  reported  by  Berger.  The  strength  of  solutions 
used  was  4  per  cent,  or  more,  as  near  as  could  be  determined,  the  total  quantity  being 
luiusually  large,  as  much  as  4.00  having  been  given;  in  2  cases,  however,  only  0.04 
and  O.OG  were  given.  The  latter  2  cases  Reclus  and  Auber  do  not  regard  as  cases  of 
eocain  poisoning.  In  the  case  reported  by  Bettelheim  severe  symptoms  manifested 
themselves  following  the  injection  of  0.01  of  eocain  in  the  forearm,  the  etiological 
explanation  of  which  appeared  doubtful  to  Woelfler.  It  is  immaterial  how  one  views 
these  cases;  nevertheless  the  fact  is  that  Weigand's  records  show  no  less  than  40  cases 
in  which  usually  harmless  doses  of  0.01  to  0.05  in  5  to  30  per  cent,  solution  were  in- 
jected, causing  symptoms  of  poisoning,  in  some  cases  very  severe.  On  the  other  hand, 
occasionally  after  the  injection  of  a  large  dose  (2.0  to  2.5,  Buebler),  only  relatively 
slight  symptoms  of  poisoning  were  observed.  We  can  conclude  from  these  observa- 
tions that,  although  the  quantity  of  eocain  injected  was  accurately  measured, 
there  are  many  circumstances  to  be  considered  in  the  causation  of  poisoning  other 
than  the  dosage.  There  may  be  a  peculiarity  in  the  constitution  of  the  individual, 
an  idiosyncrasy  toward  eocain,  or  it  may  be  that  the  eocain  itself  is  not  of  uniform 
action  in  all  cases.  Which  one  of  these  views  is  correct?  Can  eocain  poisoning  be 
prevented,  and  how? 

Physiological  Action  of  Cocain. — The  physiological  action  of  eocain  is  that  of  a 
protoplasmic  })oison,  affecting  protoplasm  whenever  it  comes  in  contact  with  it. 
The  symptoms,  therefore,  manifest  themseh-es  at  the  place  where  the  cocain  enters 
the  body  and  also  at  distant  points,  on  account  of  which  we  distinguish  between  a 
local  and  a  general  poisoning. 

Character  and  Mechanism  of  Local  Cocain  Poisoning. — Cocain  paralyzes  temporarily 
and  without  permanent  damage  to  the  tissues  the  function  of  sensory  and  motor 


80  LOCAL  ANESTHESIA 

peripheral  nerves  (Alms,  Mosso),  the  striped  and  smooth  muscle  fibers  (Albertoni, 
Sighicelli),  and  the  heart  muscle  (]\Iosso),  provided  the  solution  is  not  too  dilute 
when  brought  into  contact  with  these  structures.  When  cocain  solutions  are  applied 
to  freely  exposed  nerve  trunks,  first  the  sensory  and  later  the  motor  fibers  lose  their 
power  of  conduction  (Torsellini,  Feinberg,  Alms,  Kochs,  Witzel,  Goldscheider, 
Corning,  Mosso).  Herrenheiser  showed  that  cocain  applied  in  this  way  can  par- 
alyze the  optic  nerve,  while  Aducco  and  Mosso  (1890)  demonstrated  that  a  few  drops 
of  a  10  to  20  per  cent,  cocain  solution  placed  on  the  floor  of  the  fourth  ventricle 
of  the  brain  promptly  paralyzes  the  respiratory  centre,  but  the  animals  could  be  kept 
alive  by  artificial  respiration.  The  symptoms  of  general  cocain  poisoning  in  men  and 
animals  show  how  particularly  sensitive  the  central  nervous  system  is  to  this  drug. 
Albertoni  found  that  cocain,  applied  locally,  inhibited  the  secretion  of  glands,  the 
movements  of  spermatozoa,  ciliated  epithelium,  blood-corpuscles  of  the  cray-fish, 
lepidoptera  larvse,  and  amebse.  The  same  author  and  Maurel  noticed  that  solutions  of 
cocain  in  the  blood  paralyzed  the  leukocytes.  The  latter  lost  their  contractility  and 
power  to  penetrate  the  vessel  walls,  and  became  round  and  collected  in  capillaries. 
Danilewski,  by  the  application  of  cocain  to  the  feelers  cut  from  the  sea  anemone, 
was  able  to  see  and  study  all  the  elementary  symptoms  of  cocain  poisoning,  which 
promptly  disappeared  upon  the  removal  of  the  cause.  Charpentier,  ]Mosso,  and 
others,  showed  that  plants  are  similarly  affected  by  cocain. 

The  local  application  of  cocain  causes  contraction  of  the  small  capillaries  and 
arteries,  especially  of  the  mucous  membranes,  so  that  locally  the  blood  content  of  the 
tissues  is  temporarily  diminished.  Eversbusch,  Laborde,  and  others,  regarded  this 
oligemia  as  the  basis  of  local  and  general  cocain  poisoning.  Maurel,  after  the  most 
painstaking  efforts,  endeavored  to  prove  that  the  paralyzed  leukocytes  obstructed 
the  contracted  capillaries,  thus  causing  a  disturbance  of  function  of  the  protoplasm 
of  the  tissues.  It  was  known  long  before  these  observations  of  Maurel  that  the  action 
of  cocain  was  independent  of  the  blood  contents  of  the  organs.  As  proof  of  these 
facts  it  might  be  mentioned  that  cold-blooded  animals  which  can  live  for  some  time 
without  blood,  and  organisms  which  have  no  circulatory  system,  react  constantly 
upon  cocain.  If  the  blood  of  frogs  is  replaced  by  a  solution  of  sodium  chloride 
they  will  show  the  same  symptoms  of  local  and  general  cocain  poisoning  as  normal 
frogs  or  other  warm-blooded  animals.  Excised  organs  (nerve-muscle  preparation) 
of  warm-blooded  animals,  while  still  in  a  li\'ing  state,  do  not  react  differently  upon 
cocain  than  those  in  the  living  animal.  Arloing  cocainized  the  eye  of  a  rabbit  and 
then  cut  the  sympathetic  of  the  same  side;  although  the  conjunctiva  immediately 
became  markedly  hyperemic,  the  anesthesia  persisted.  It  might  be  mentioned  in 
this  connection  that  the  newer  local  anesthetics  in  part  act  similarly  to  cocain, 
except  that  they  do  not  cause  contraction  of  the  bloodvessels,   with  consequent 


LOCAL  ANESTHETIC  AGENTS  81 

oliii'eniia  and  anemia  of  the  tissnes;  likewise  many  symptoms  of  oocain  i)()isoning, 
partieularly  the  rapidly  ensuing  loss  of  pain  sense,  do  not  occur.  The  influence 
of  the  anemia  of  the  tissues  indirectly  causes  a  retardation  of  the  circulation,  the 
absorption  of  cocain  taking  place  more  slowly,  thereby  producing  a  more  intense 
local  effect. 

A  direct  effect  of  anemia  on  the  symptomatology  of  cocain  poisoning  can  only 
be  considered  when  organs  easily  affected  by  variations  in  their  blood-content  or 
pressure  like  the  l)rain  cortex  are  concerned.  ^Ye  will  consider  this  subject  again 
in  another  chapter. 

The  paralysis  of  leukocytes,  contraction  of  bloodvessels  and  anemia,  are  not  the 
cause  but  the  consequence  or  the  effect  of  cocain  poisoning,  and  are  best  explained 
as  due  to  a  chemical  affinity  of  cocain  for  the  protoplasm.  The  nature  of  the  chemical 
combination  of  the  protoplasm  with  cocain  is  not  known;  it  can  be  assumed,  however, 
that  it  must  be  a  very  loose  one,  which  can  be  broken  up  as  readily  as  it  occurs, 
permitting  the  function  of  the  affected  tissues  to  return  to  the  normal.  The  disinte- 
gration of  these  combinations  is  intimately  associated  with  the  vital  forces  of  the 
tissues,  and  the  symptoms  of  local  cocain  poisoning  can  under  certain. conditions 
be  continued  indefinitely  by  interrupting  the  circulation  of  the  part.  P'rom  certain 
peculiarities  of  cocain  poisoning  it  is  probable  that  cocain  which  has  once  entered  into 
chemical  combination  is  not  taken  up  b}'  the  circulation  as  such,  but  is  split  into 
its  component  molecules.  This  is  in  accord  with  the  fact  that  in  the  excreta  and 
organs  of  animals  poisoned  by  cocain,  little  or  no  cocain  can  be  found.  According 
to  \Yiechowski's  investigations,  a  dog  eliminates  5.1  per  cent.,  a  rabbit  no  part  of  a 
toxic  dose  of  cocain;  nevertheless,  from  the  organs  of  recently  killed  animals  treated 
with  cocain  solutions  the  larger  part  (80  per  cent.)  may  be  reco^•ered.  The  dis- 
integration of  the  alkaloids  must  have  some  association  with  the  vital  processes. 
The  older  experiments  of  Helmsing  (1886)  are  not  very  valuable,  since  at  that  time 
there  was  no  known  chemical  reaction  for  cocain;  still,  the  author  supposes  that 
the  cocain  was  disintegrated  within  the  body  of  the  animal. 

\'arious  forms  of  protoplasm,  different  organisms  or  parts  of  organisms,  are  not 
equally  susceptible  to  cocain ;  one  variety  of  protoplasm  requires  a  larger  dose  than 
another  before  showing  evidence  of  poisoning.  The  extent  of  cocain  poisoning  is 
quite  variable;  at  times  the  stage  of  excitation  preceding  every  cocain  paralysis 
is  very  slight  or  not  at  all  noticeable;  at  other  times  the  paralysis  is  preceded  by  the 
most  severe  irritation.  Very  slight  degrees  of  poisoning  evidence  themselves  merely 
by  excitation  and  functional  stimulation,  which  symptoms  produced  by  the  use  of 
coca  leaves,  gave  the  latter  historical  prominence.  The  cerebral  cortex  is  most 
sensitive  to  the  action  of  cocain,  then  the  medulla  oblongata  and  cord.  The  symp- 
toms of  general  cocain  intoxication  in  warm-blooded  animals  are  evidenced  by  a 
6 


82  LOCAL  ANESTHESIA 

disturbance  of  function  in  these  organs,  giving  rise  to  such  symptoms  as  intense 
excitement,  convulsions  and  paralysis. 

The  peripheral  sensory  nerves  are  likewise  very  sensitive  toward  cocain,  whether 
it  reaches  them  by  absorption,  from  a  mucous  membrane,  from  injection  directly 
into  the  tissues,  or  by  means  of  the  blood-supply  (Alms,  Maurel).  The  sensitiveness 
of  the  sensory  end  organs  of  the  human  skin  can  be  definitely  determined  by  means  of 
the  skin  wheal.  The  addition  of  0.005  per  cent.  (1  to  20,000)  of  cocain  to  an 
indifferent  solution,  such  as  0.9  per  cent,  salt  solution,  when  injected  into  the  skin 
is  sufficient  to  obliterate  the  sense  of  pain  for  a  short  time  in  the  area  injected 
(Braun,  Heinze). 

More  dilute  solutions  show  no  such  effect.  Dilute  and  osmotically  indifferent 
solutions  of  cocain  are  painless  when  injected;  concentrated  solutions  of  3  to  4  per 
cent,  cause  sudden  sharp  pain,  to  be  immediately  followed  by  complete  local  paralysis. 
The  duration  of  anesthesia  varies  with  location  and  individual  susceptibility,  and 
increases  with  the  strength  of  the  solution.  If  the  anesthetic  wheal  produced  by  the 
injection  of  a  1  per  cent,  solution  lasts  tw^enty-five  minutes,  the  injection  of  a  0.1 
per  cent,  solution  in  the  same  person  and  the  same  place  will  last  only  eighteen 
minutes.    The  freezing-point  of  various  cocain  solutions  is  as  follows: 

0. 1  per  cent,  solution,  freezing-point 0.02   ° 

1 . 0  per  cent,  solution,  freezing-point 0.115° 

2 . 0  per  cent,  sulution,  freezing-point 0 .  23    ° 

3 . 0  per  cent,  solution,  freezing-point 0.305° 

4.0  per  cent,  solution,  freezing-point 0.41    ° 

5.8  per  cent,  solution,  freezing-point 0.565° 

It  will  be  seen  that  the  physiological  concentration  is  about  5.8  per  cent.  Weaker 
solutions  than  this  (as  low  as  0.5  per  cent.)  cause  cellular  swelling  and  pain  upon 
injection,  the  latter  often  being  obscured  by  the  rapidly  following  paralysis.  Watery 
solutions  of  0.01  per  cent,  cause  severe  pain  upon  injection.  Injury  to  the  tissues 
is  not  noticed  after  the  use  of  weak,  osmotically  indifferent  cocain  solutions. 
The  swelling  rapidly  disappears  without  leaving  an}^  infiltration  or  other  local 
changes.  The  intensity  and  extent  of  anesthesia  produced  by  diffusion  of  the  solu- 
tion depends  upon  its  concentration;  the  anesthesia  following  the  use  of  weak  solu- 
tions is  limited  to  the  area  injected.  Following  the  injection  of  2  per  cent,  cocain 
solutions  a  relatively  large  anesthetic  and  hemianesthetic  area  surrounds  the  place 
of  injection.  If  a  0.1  per  cent,  solution  of  cocain  is  injected  into  the  subcutaneous 
connective  tissue  the  overlying  skin,  as  a  rule,  will  not  show  any  pronounced  change 
of  sensation;  but  if  the  strength  of  the  solution  is  increased  to  2  per  cent,  or  more, 
not  only  does  the  skin  become  anesthetic  but  also  the  deeper  parts,  such  as  fascia, 
muscle,  periosteum,  etc.  In  like  manner  cocain  solutions  will  interrupt  the  conduc- 
tivity of  nerve  trunks  if  injected  into  their  immediate  neighborhood  in  sufficiently 


I 


LOCAL  ANESTHETIC  AGENTS  83 

concentrated  solution  (2  to  4  per  cent.).  \Ve  will  a^ain  refer  to  tlie  history,  theory, 
and  practical  application  of  this  method.  In  regard  to  increasing  the  local  effect 
of  cocain  by  preventing  its  absorption  see  Chapter  Vlll. 

Goldscheider  found  upon  studying  the  relation  of  cocain  to  the  various  sensations 
of  the  skin  that  the  temperature  sense  and  sensation  of  tickling  were  most  suscep- 
tible to  its  action.  He  likewise  made  the  remarkable  observation  that  although 
the  skin  or  mucous  membrane  of  the  tongue  was  anesthetized  and  the  temperature 
sense  completely  obliterated,  nevertheless  hyperalgesia  to  irritation  from  heat  was 
present.  To  be  more  definite,  he  found  that  where  moderate  warmth  applied  to 
the  normal  skin  produced  only  a  feeling  of  difference  in  temperature,  in  the  cocain- 
ized skin  or  mucous  membrane  it  produced  severe  pain.  The  correctness  of  these 
observations  of  Goldscheider  have  been  verified. 

Touch  and  pressure  sense  are  less  sensitive  to  the  action  of  cocain  than  the  pain 
sense,  it  being  frequently  observed  that  after  the  local  application  of  cocain,  although 
analgesia  is  present,  touch  and  pressure  sense  are  not  disturbed.  After  the  appli- 
cation of  cocain,  in  a  solution  of  definite  strength  and  when  complete  anesthesia 
has  been  induced,  touch  and  pressure  sense  return  first,  then  pain  sense,  and  lastly 
the  temperature  sense.     These  observations  do  not  agree  with  those  of  Goldscheider. 

This  experiment  can  best  be  carried  out  by  injecting  into  the  cutis  0.001  to  0.1 
per  cent,  cocain  solution  in  0.9  per  cent,  salt  solution.  A  considerable  area  will  thus 
be  anesthetized,  the  degree  of  anesthesia  depending  upon  the  concentration  of  the 
solution.  In  this  area  the  reaction  of  the  senses  to  irritation  can  be  accurately  tested. 
The  quantity  of  cocain  used  is  so  small  that  any  symptoms  of  a  general  nature  can 
be  excluded,  although  IVIosso  (1890)  noticed  an  increasing  hyperesthesia  of  the  entire 
skin  after  the  internal  administration  of  0.05  to  0.1  cocain  in  man.  It  can  also  be  de- 
termined that  the  duration  of  anesthesia  increases  with  the  concentration  of  the  solu- 
tion. It  can  be  further  shown  that  the  weakest  solutions  (0.001  to  0.003  per  cent.), 
the  concentration  ^'arying  with  the  time  and  individual,  cause  a  loss  of  temperature 
sense  only  and  a  hyperalgesia  toward  irritation  from  heat.  Slightly  stronger  solutions 
(0.005  per  cent.)  cause  analgesia,  and  still  stronger  solutions  cause  a  loss  of  all  sensa- 
tion. If  the  course  of  the  anesthesia  is  now  tested,  it  will  be  constantly  noted 
that  touch  and  pressure  sense  return  first,  pain  sense  next,  and  last  the  temperature 
sense.  It  will  also  be  noticed  during  the  disappearance  of  the  anesthesia,  when 
cutting,  pricking  the  skin,  and  faradic  irritations  are  scarcely  recognized  as 
pain,  that  hyperalgesia  to  the  irritation  of  heat  is  present.  This  observation  is  of 
considerable  practical  significance  in  surgery  and  offers  an  explanation  of  the  fact 
that  the  use  of  the  thermocautery  on  tissues  anesthetized  with  cocain  causes  a 
rapid  return  of  pain  sense.    We  now  have  no  further  need  for  the  improbable  theory 


84  LOCAL  ANESTHESIA 

of  Reclus,  that  the  effect  of  the  heat  of  the  thermocautery  caused  a  more  rapid 
destruction  of  the  cocain  present  in  the  tissues. 

Cocain  appHed  to  mucous  membranes  paralyzes  not  only  the  pain  sense  but  also 
the  other  inherent  senses  such  as  taste  and  smell  (Zwaardemacker). 

The  motor  nerves  are  so  much  less  sensitive  to  cocain  than  the  sensory  nerves, 
that  it  has  been  held  that  they  are  immune,  but  Alms  and  Kochs,  later  Mosso  (1890), 
Laewen,  and  Gros  demonstrated  that  this  was  not  the  case.  Mosso,  following  the 
application  of  cocain  to  the  nerves  of  the  diaphragm  of  a  dog,  observed  a  rapidly 
ensuing  paralysis  of  this  structure.  Frank  utilized  this  property  of  cocain  in  his 
physiological  experiments  on  living  animals,  in  place  of  cutting  the  nerves.  Alms 
and  Maurel  injected  cocain  into  an  artery  of  an  animal  and  noted  a  motor  paralysis 
in  the  area  supplied  by  it.  Mosso  replaced  the  blood  in  the  vessels  of  the  extremities 
of  frogs  and  warm-blooded  animals  with  salt  solutions  and  defibrinated  blood  con- 
taining cocain  in  various  quantities.  If  the  solution  contained  0.6  per  cent,  of  cocain, 
the  muscles  were  first  stimulated,  then  paralyzed,  returning  to  normal  when  the  vessels 
were  flushed  with  salt  solution  or  blood.  If  the  above  solutions  contained  larger 
quantities  of  cocain,  paralysis  ensued  immediately.  In  experiments  on  conduction 
anesthesia  in  man,  an  interruption  of  conductivity  of  both  motor  and  vasomotor 
tracts  of  mixed  nerves  occurred  when  the  action  of  the  cocain  was  sufficiently 
intense;  the  sensory  tracts  were,  however,  more  quickly  paralyzed  and  the  anesthesia 
w^as  of  longer  duration  than  the  motor  paralysis.  If  the  action  of  the  cocain  was  less 
intense,  motor  paralysis  did  not  occur,  whereas  sensory  paralysis  was  complete. 

According  to  Mosso  the  frog's  heart  becomes  stimulated  when  salt  solution  con- 
taining 0.04  per  cent,  cocain  is  passed  through  it,  and  paralyzed  when  0.08  per  cent, 
of  cocain  is  contained  in  the  solution,  the  heart  returning  to  normal  if  no  further 
addition  of  this  substance  is  made.  Albertoni  was  able  to  paralyze  the  larva?  of  lepi- 
doptera  and  ameba,  when  placed  in  0.5  per  cent,  cocain  solution.  In  regard  to  the 
sensitiveness  of  plants  it  has  been  found  that  0.05  to  0.1  per  cent,  cocain  solutions 
accelerate  the  germination  of  the  seed  and  the  growth  of  the  plant,  1  per  cent,  solu- 
tions hinder  these  processes,  while  2  per  cent,  solutions  cause  a  complete  interference 
with  growth  and  development.  The  leukocytes  are  particularly  sensitive  to  cocain. 
Maurel  states  that  the  leukocytes  are  paralyzed  by  the  addition  of  0.02  per  cent, 
cocain  to  the  human  blood.  The  collection  of  immobile  leukocytes  in  the  capillaries 
constantly  occurs  in  general  cocain  poisoning,  but  has  not  the  significance  ascribed 
to  them  by  Maurel.  Since  the  sensory  nerves  have  been  shown  to  be  most  sensitive 
to  cocain,  it  is  only  natural  to  ascribe  to  cocain  a  certain  specific  action  upon  the 
peripheral  sensory  nerves.  Until  the  discovery  of  cocain,  there  was  no  known  sub- 
stance which  was  able  to  exert  a  decided  action  upon  the  peripheral  sensory  nerves 
without  marked  irritation  or  permanent  damage  to  them. 


LOCAL  ANESTHETIC  AGENTS  85 

The  term  "sensitive  curare,"  whicli  was  ai)i)lie(l  to  cocain  l)y  Aiirep,  Lafloiite, 
Laborde,  and  Dastre,  is  certainly  applicable,  as  the  motor  and  sensory  jjaralysis  fol- 
lowing the  ingestion  of  toxic  doses  of  cocain  are  central  in  nature,  and  are  not  due 
to  the  action  of  this  agent  ui)on  the  peripheral  nerves  (^VIosso). 

Character  and  Mechanism  of  General  Cocain  Poisoning. — Cocain  introduced  into 
the  body  and  absorbed  into  the  circulation  may  act  upon  the  protoplasm  of  organs 
in  places  remote  from  the  point  of  introduction.  These  organs  will  respond  to  the 
toxic  agent  with  irritation  or  paralysis,  if  the  blood  passing  through  them  contains 
cocain  in  sufficient  quantity  to  effect  them.  This  rule  formulated  by  Albertoni  is 
the  key  to  the  understanding  of  the  peculiar  manifestations  of  local  or  general  cocain 
poisoning. 

The  historically  important  property  of  small  doses  of  cocain  was  studied  by  ]Man- 
tegazza  among  the  natives  who  chewed  the  coca  leaf.  He  observed  that  motion 
and  sensation  were  temporarily  stimulated  within  normal  limits,  perception  and  trans- 
mission of  nerve  impulses,  as  well  as  metabolism,  were  increased.  This  was  later 
obser^•ed  by  Anrep,  Mosso,  Fleischer,  Freud,  and  others,  to  apply  to  the  use  of  pure 
cocain.  This  undoubted  central  action  of  small  doses  of  cocain  is  of  little  importance 
in  the  consideration  of  our  subject.  To  better  understand  the  rapidly  changing  picture 
of  acute  cocain  poisoning  following  the  introduction  into  the  body  of  large  doses 
of  this  poison,  we  will  follow  the  description  of  Husemann.  In  studying  the  symp- 
tomology  of  this  condition  we  find  the  chief  disturbance  in  the  organs  most  sensitive 
to  cocain,  namely,  the  central  nervous  system.  In  the  mildest  form  of  poisoning 
there  is  a  sudden  but  usually  transient  attack  of  vertigo  quickly  following  the  appli- 
cation of  the  cocain.  This  attack  may,  however,  become  more  severe  and  be  followed 
by  collapse,  small  compressible  pulse,  formication,  cold  extremities,  irregular,  difficult 
respiration  and  cold  sweat.  In  more  severe  cases  these  symptoms  are  accompanied 
by  unconsciousness,  and  followed  by  symptoms  of  general  weakness  lasting  several 
hours.  Vomiting  is  frequently  associated  with  this  condition.  As  previously  men- 
tioned, it  is  possible,  or  rather  probable,  that  the  cerebral  anemia  present  in  the  milder 
forms  of  cocain  poisoning  has  a  certain  but  unimportant  part.  The  symptom  com- 
plex indicates  a  severe  degree  of  poisoning  of  the  central  nervous  system,  characterized 
by  more  or  less  excitation  of  the  cerebral  cortex  (cocainrausch).  The  patients  are 
unnaturally  excited;  they  are  usually  in  good  spirits,  laugh,  chatter,  have  hallucina- 
tions and  very  frequently  melancholia  and  ideas  of  persecution.  Various  abnormal 
subjective  sensations  occur,  such  as  dryness  of  the  throat,  precordial  fear,  parasthesia, 
anesthesia,  loss  of  sight,  smell,  and  hearing.  The  pupils  are  dilated  and  fixed  as  after 
the  local  instillations  of  cocain  into  the  eye;  the  excitation  may  develop  into  mania. 
Severe,  dangerous  cocain  poisoning  almost  always  begins  with  severe  epileptiform 
convulsions  with  exophthalmos  and  unconsciousness,  followed  by  loss  of  sensation. 


80  LOCAL  ANESTHESIA 

motion,  reflexes,  and  lastly  the  corneal  reflex.  The  patients  are  in  deep  coma  and  death 
ensues  in  consequence  of  paralysis  of  the  respiratory  centre.  A  succession  of  the 
phenomena  of  cocain  poisoning  is  similar  to  that  of  the  inhalation  anesthetics,  such 
as  chloroform,  ether,  etc.,  except  that  in  the  latter  the  symptoms  of  irritation  are 
slight,  those  of  paralysis  predominating,  while  in  the  former  the  symptoms  of  irrita- 
tion of  the  central  nervous  system  are  most  prominent.  Individuals  having  a  ten- 
dency to  convulsions  develop  these  symptoms  much  more  readily  than  others  after 
the  use  of  cocain.  It  has  been  noticed  in  nervous  individuals  that  convulsions  have 
occasionally  occurred  three  to  four  weeks  after  the  poisoning.  The  manifold  symp- 
toms of  acute  cocain  poisoning  have  not  been  exhausted  with  this  description,  as 
there  is  hardly  a  pathological  symptom  of  the  body  which  has  not  been  observed  in 
this  condition.  Experimental  investigations  regarding  general  cocain  poisoning 
in  animals  have  been  made  by  von  Schroff  (1862),  Danin  (1873),  von  Anrep  (1879), 
Volpian  (1883),  Mosso,  (1887),  Albertoni  (1890),  Maurel  (1892),  and  many  others, 
and  the  association  of  the  phenomena  explained.  As  in  man  the  symptoms  are 
confined  almost  entirely  to  the  central  nervous  system.  In  intelligent  animals,  as 
dogs,  after  the  use  of  small  doses  of  cocain  a  similar  irritation  of  the  psychic  centres 
is  observed  the  same  as  in  man,  excitation,  depression,  and  hallucinations  (Feinberg, 
Blumenthal,  and  Mosso).  Every  severe  case  of  poisoning  in  warm-blooded  animals 
begins  immediately  after  the  administration  of  cocain,  with  severe  clonic  convulsions, 
exophthalmos  and  loss  of  consciousness.  In  cold-blooded  animals  convulsions  are 
absent.  In  warm-blooded  animals  they  may  be  absent  or  almost  so,  if  the  poison  is 
administered  gradually  in  dilute  solutions.  As  is  observed  in  man,  the  convulsions 
are  succeeded  by  coma,  with  loss  of  consciousness,  motion,  and  the  reflexes, 
death  ensuing  during  or  after  the  stage  of  convulsion  from  paralysis  of  respiration. 
Feinberg  and  Blumenthal  have  demonstrated  the  central  origin  of  cocain  convulsions, 
the  symptoms  not  occurring  in  animals  in  which  the  cortical  motor  centres  have 
been  extirpated.  These  symptoms  are  likewise  absent  in  newborn  animals  in  which  the 
cortical  centres,  according  to  Soltmann,  cannot  be  stimulated  before  the  twentieth 
day.  Finally,  these  symptoms  do  not  occur  if  the  cerebral  cortex  has  been  previously 
paralyzed  with  chloroform,  ether  or  chloral  hydrate  (Mosso).  The  observations  of 
Feinberg  and  Blumenthal,  which  were  later  verified  by  Soulier  and  Guinard,  seemed 
to  point  to  cerebral  anemia  as  the  cause  of  the  convulsions.  There  can  be  no  further 
doubt  at  present  that  the  specific  effect  of  the  poison  on  the  central  nervous  system 
is  the  cause  of  the  stimulation  of  the  cortex.  In  the  first  place,  the  brain  is  not  anemic 
during  the  stage  of  convulsions,  but,  to  the  contrary,  enormously  overfilled  with  blood, 
for  which  reason  we  notice  the  condition  of  exophthalmos,  and,  secondly,  drugs  closely 
related  to  cocain  in  their  action,  but  which  do  not  cause  cerebral  anemia,  give  rise 
to   similar  convulsions   (tropacocain) .     Sensory  and   motor  paralyses,   caused   by 


LOCAL  ANESTHETIC  AGENTS  87 

cocain,  are  purely  of  central  oriiiin,  as  shown  ])y  ]\Iosso,  for  even  in  the  deepest 
eoma,  muscles  and  peripheral  nerves  retain  their  power  of  reacting  to  stimuli,  while 
on  the  other  hand  paralysis  of  an  extremity  does  not  occur  when  excluded  from  the 
circulation   of  the  poisoned   animal. 

During  the  experiments  on  animals  poisoned  by  cocain  many  peculiarities  of  the 
effect  of  this  drug  should  be  noted  which  find  their  exi)lanation  in  the  action  of 
this  alkaloid  upon  the  protoplasm.  We  have  learned  that  the  chief  properties 
of  cocain  are:  (1)  Its  marked  affinity  for  living  protoplasm  of  all  kinds,  which  causes 
its  fixation  as  soon  as  the  substance  is  introduced  into  the  body.  (2)  Its  ability 
to  enter  into  less  stable  compounds  with  the  protoplasm  whose  functions  are  tem- 
porarily interrupted  and  its  rapid  disintegration,  which,  therefore,  prevents  its  entering 
the  circulation  again  as  cocain.  These  properties  form  the  basis  of  the  local  anesthetic 
qualities  of  the  drug  and  explain  the  following  peculiarities  of  cocain  poisoning: 

If  cocain  solutions  be  injected  intravenously  into  animals,  they  react  promptly 
and  uniformly  to  definite  doses  of  cocain,  provided  the  doses  are  dissolved  in  the 
same  quantity  of  water  or  other  solvents.  The  same  dose  will  act  differently,  how- 
ever, if  of  different  concentration,  or  if  instead  of  being  administered  as  one  dose  is 
injected  at  short  intervals.    This  reaction  of  cocain  was  first  studied  by  Maurel. 

According  to  the  experiments  of  Maurel,  if  0.01  cocain  in  5  per  cent,  solution  be 
injected  into  a  vein  in  the  ear  of  a  rabbit,  death  immediately  follows;  0.005  per  kilo 
causes  violent  convulsions;  0.0025  causes  mild  symptoms  of  poisoning.  If  0.002 
per  kilo  in  5  per  cent,  solution  be  repeatedly  injected  intravenously  at  intervals  of 
five  to  ten  minutes,  0.03  per  kilo  of  cocain  can  be  given  without  the  occurrence  of 
poisoning.  Poisoning  will  likewise  not  occur  if  0.03  per  kilo  of  cocain  be  injected 
in  0.25  per  cent,  instead  of  a  5  per  cent,  solution.  Similar  experiments  by  the  author 
were  reported  by  Weigand  as  follows:  three  rabbits  of  approximately  the  same 
weight  (1800  gm.)  were  injected  in  a  vein  in  the  ear  with  cocain,  the  first,  0.005 
in  10  per  cent,  solution;  result:  severe  convulsions  and  paralysis;  the  second,  0.005 
in  1  per  cent,  solution;  result:  no  poisoning;  the  second  0.01  in  1  per  cent,  solution; 
result:  short,  violent  convulsions;  the  third,  0.02  in  0.2  per  cent,  solution;  result: 
transient  weakness;  the  third,  0.02  in  0.1  per  cent,  solution;  result:  no  poisoning. 

It  will  be  noted  from  the  above  that  four  times  the  quantity  of  cocain  will  be  borne 
by  an  animal  in  0.01  per  cent,  solution  without  injury,  which  in  a  10  per  cent,  solu- 
tion causes  very  severe  symptoms  on  the  part  of  the  central  nervous  system.  The 
weakening  of  the  toxic  effect  of  a  quantity  of  cocain  injected  intravenously  in  divided 
doses  was  observed  by  Feinberg  and  Blumenthal  in  their  experiments  on  dogs.  The 
explanation  of  these  facts  is  determined  by  the  properties  of  cocain.  The  latter, 
introduced  into  the  blood,  irritates  and  paralyzes  the  susceptible  nervous  system, 
before  the  other  organs  have  had  an  opportunity  to  react,  although  they  were  equally 


88  LOCAL  ANESTHESIA 

exposed  to  its  toxic  action.  Cocain  poisoning  of  the  central  nervous  system,  that  is, 
the  picture  of  general  cocain  poisoning,  occurs  when  the  blood  passing  through  the 
central  nervous  system  contains  the  alkaloid  in  a  sufficiently  active  concentration  for 
this  organ,  even  if  the  contact  with  it  be  but  momentary.  If  this  concentration  be 
less,  repeated  doses  of  cocain  may  be  administered  for  a  time,  as  the  small  quantities 
contained  in  the  blood  become  immediately  combined  and  ultimately  disintegrated. 
Acute  poisoning  will  therefore  not  occur,  as  the  living  cells  of  the  central  nervous 
system  can  withstand  and  render  harmless  the  small  doses  they  receive  as  long  as 
the  cocain  and  its  disintegration  maintain  a  definite  balance.  These  conditions  are 
very  similar  to  those  resulting  from  the  inhalation  of  ether  and  chloroform.  These 
substances  do  not  possess  a  maximum  dose.  A  small  quantity  of  either  of  them  can 
cause  a  paralysis  of  the  centres  in  the  medulla  oblongata  with  instant  death  of  the 
patient,  if  contained  in  the  blood  in  concentrated  form.  Many  hundred  times  this 
quantity  can  be  gradually  administered,  as  the  degree  of  poisoning  from  either  chloro- 
form or  ether  depends  entirely  upon  the  quantity  of  their  vapor  in  the  respired 
air  of  the  individual.  The  occurrence  and  intensity  of  cocain  poisoning  are  not 
alone  dependent  upon  the  quantity  given,  but  also  upon  the  time  during  which  it 
is  administered.  If  introduced  into  the  blood  suddenly,  that  is,  in  concentrated 
solution,  death  may  occur  immediately,  while  if  gradually  introduced,  that  is,  in  dilute 
solution  or  if  given  in  divided  doses,  poisoning  will  not  manifest  itself,  as  the  concen- 
tration of  cocain  in  the  capillaries  of  the  central  nervous  system  is  never  of  sufficient 
concentration  to  be  toxic  to  this  organ.  The  toxic  effect  of  concentrated  and  dilute 
solutions  is  not  so  marked  with  other  substances  as  it  is  with  cocain.  Poisons  which 
at  their  point  of  application  produce  stable  changes  and  accumulate  do  not  show 
the  phenomena  to  such  a  marked  degree,  as  they  must  be  administered  gradually 
in  repeated  doses,  in  consequence  of  their  cumulative  action.  This  finally  brings 
about  the  same  condition  as  when  a  like  dose  is  rapidly  absorbed.  We  shall  later 
study  the  action  of  the  drug  "akoin,"  a  local  anesthetic  which  belongs  to  this  class 
of  poisons. 

Animals  can  withstand  much  larger  quantities  of  cocain  solution  injected  into 
the  subcutaneous  connective  tissue,  or  between  the  muscles,  than  when  the  same 
quantity  and  of  like  concentration  is  injected  into  the  veins,  leaving  out  of  considera- 
tion temporarily  some  of  the  irregularities  of  action  of  this  alkaloid.  Custer  observed 
that  0.03  per  kilo  in  a  5  per  cent,  solution  was  the  smallest  quantity  that  would  show 
evidence  of  poisoning  in  rabbits,  and  that  0.1  per  kilo  was  always  a  fatal  dose. 
Experiments  by  the  author  show  that  0.02  per  kilo  in  a  10  per  cent,  solution  caused 
no  symptoms,  0.03  per  kilo  was,  as  a  rule,  followed  by  poisoning,  and  exitus  lethalis 
occurred  regularly  after  the  administration  of  0. 1  per  kilo.  Most  authorities  consider  the 
dose  of  0.1  per  kilo  fatal  for  rabbits.     The  dose  which  can  be  administered  to  rabbits 


LOCAL  ANESTHETIC  AGENTS  89 

siibciitaneoiisly  without  toxic  or  fatal  effect  is  almost  ten  times  as  lartje  as  that  which 
can  be  administered  intravenously.  The  cause  for  this  difference  lies  mainly  in  the 
delayed  absorption  of  the  alkaloid,  part  of  which  enters  into  a  local  combination 
with  the  tissues,  the  remainder  reaching  the  central  nervous  system  in  more  dilute 
form.  However,  in  intravenous  injections  the  full  dose  cannot  reach  the  central  nervous 
system,  inasmuch  as  the  paralyzed  leukocytes  fill  the  capillaries  and  must  necessarily 
absorb  a  portion  of  the  poison.  The  affinity  of  cocaine  for  all  tissues,  and  their  powder 
of  reducing  portions  of  the  drug  is  best  shown  when  the  solutions  are  introduced  subcu- 
taneously.  It  will  again  be  seen  that  the  effectiveness  of  the  dose  administered  sub- 
cutaneously  is  dependent  in  large  measure  upon  the  concentration  of  the  solution. 
Ponchet  injected  two  guinea-pigs  of  equal  weight,  one  with  0.04  cocain  in  4  per  cent, 
solution,  the  other  0.1  in  0.66  per  cent,  solution;  the  first  died  after  a  few  seconds, 
the  second  was  poisoned  but  did  not  die.  Experiments  on  rabbits  demonstrated  that 
a  5  to  10  per  cent,  solution  containing  0.1  of  cocain  per  kilo  was  fatal,  whereas  the 
same  quantity  administered  in  a  1  per  cent,  solution  caused  mild  symptoms  of  poi- 
soning or  none  at  all.  It  was  also  shown  that  cocaine  in  dilute  solutions  did  not  pro- 
duce convulsions  to  the  same  extent  as  the  more  concentrated  ones.  x\ccording  to 
jNIaurel,  0.025  of  cocain  in  0.1  per  cent  solution  is  fatal  for  rabbits,  while  experi- 
ments by  Custer  and  others  demonstrated  that  0.1  per  kilo  in  0.1  per  cent  solution 
did  not  produce  poisoning;  the  first  toxic  symptoms  showed  themselves  only  after 
the  administration  of  0.15  per  kilo,  and  even  after  the  administration  of  0.3  per  kilo 
death  did  not  occur.  The  widely  varying  results  of  Maurel's  experiments  can  be 
explained  by  the  fact  that  he  used  large  quantities  of  a  watery  solution  of  cocain  for 
subcutaneous  injections.  The  animals  did  not  die  of  cocain  poisoning,  but,  as  Custer 
has  shown,  in  consequence  of  the  injection  of  water,  which  could  have  Ijeen  prevented 
by  the  addition  of  salt  to  the  solution. 

Thus  a  quantity  of  cocain  injected  subcutaneously  in  5  to  10  per  cent,  solution 
causes  the  same  toxic  symptoms  as  5  times  the  quantity  in  0.1  per  cent,  to  0.2  per 
cent,  solution,  the  reasons  for  which  have  been  previously  given.  ]\Iaurel  made  most 
interesting  observations  following  the  injection  of  cocain  solutions  into  the  arteries 
of  rabbits  instead  of  into  their  veins.  He  found  that  he  could  inject  0.1  per  kilogram 
in  10  per  cent,  solution  into  the  femoral  or  renal  artery  without  causing  any  evidence 
of  poisoning,  whereas  the  control  animals  died  after  injecting  0.02  per  kilogram  into 
their  veins.  Maurel's  explanation  of  the  action  of  cocain  is  certainly  incorrect,  no 
matter  how  plausible  it  may  seem.  In  1909,  the  author  injected  into  the  femoral  artery 
of  a  rabbit  weighing  3000  grams  0.1  cocain,  corresponding  to  0.033  per  kilogram  in  10 
per  cent,  solution,  with  an  immediately  fatal  result.  In  the  case  of  a  second  animal  the 
injection  of  0.01  per  kilogram  in  10  per  cent,  solution  into  the  femoral  artery  caused 
severe  symptoms  of  poisoning,  but  the  animal  did  not  die.     It  is  very  necessary  in 


90  LOCAL  ANESTHESIA 

these  experiments  to  be  sure  that  the  arterial  circidation  is  not  in  any  way  inter- 
ferred  with  during  and  after  the  injection,  so  that  the  cocain  as  intended,  can 
immediately  enter  the  circulation. 

Mosso  noticed  that  dogs  sometimes  respond  differently  than  usual  to  concentrated 
cocain  solutions  injected  subcutaneously.  One  dog  failed  to  be  poisoned  by  0.02 
to  0.03  per  kilo,  while  another  one  died  quickly  after  the  same  dose  (0.03).  Any  one 
who  has  made  such  experiments  must  have  come  to  the  conclusion  that  we  cannot 
without  some  reserve  speak  of  a  fatal  toxic  or  non-toxic  dose  when  using  cocain  in 
this  manner.  In  experiments  on  animals  the  same  uncertain  action  of  cocain  is 
encountered  as  has  been  noted  in  the  history  of  cocain  anesthesia  in  man,  causing  the 
widespread  belief  in  an  idiosyncrasy  toward  this  drug.  It  is  certain  that  there  are 
persons  more  susceptible  to  the  action  of  cocain  than  others,  but  in  the  large  majority 
of  cases  poisoning  following  the  injection  of  small  doses  of  cocain  must  be  explained 
otherwise  than  by  an  idiosyncrasy.  The  difficulty  of  determining  the  proper  dosage 
of  cocain  is  noted  in  animal  experimentation  as  well  as  in  the  later  observations  in 
man.  In  animals  the  irregular  action  of  cocain,  such  as  the  toxicity  of  relatively 
small  doses  or  the  harmlessness  of  correspondingly  large  ones,  becomes  evident  when 
concentrated  solutions  are  used  subcutaneously.  Intravenous  injections  of  cocain 
show  a  positive  relation  between  the  concentration  of  the  solution  and  the  symptoms 
following.  It  has  been  repeatedly  demonstrated  that  the  so-called  idiosyncrasy  in 
man  disappears  if,  instead  of  a  concentrated,  a  dilute  solution  of  cocain  is  used  for 
injection.  It  has  been  shown  that  an  animal  will  react  differently  to  a  certain  dose 
of  cocain  at  different  times.  If  0.03  per  kilo  of  cocain  in  a  10  per  cent,  solution  is 
injected  subcutaneously  into  a  rabbit,  severe  symptoms  of  poisoning  will  usually 
occur,  such  as  convulsions  with  consequent  paralysis,  without,  however,  causing  its 
death.  On  June  19,  1898,  a  rabbit  weighing  2850  grams  was  injected  under  the  skin  of 
the  back  with  1  c.c.  of  a  10  per  cent,  cocain  solution  (0.035  per  kilogram)  without 
being  poisoned.  This  animal  reacted  in  like  manner  several  days  before  to  0.03  per 
kilogram,  and  did  so  again  three  days  later.  This  speaks  against  Aducco's  theory  of  a 
cumulative  action  of  the  drug,  and  also  against  a  tolerance  of  the  drug  as  suggested 
by  Custer.  Similar  observations  have  been  frequently  made  on  human  beings,  prin- 
cipally following  the  anesthetizing  of  mucous  membranes  where  exact  dosage  was 
impossible.  Weinreich  reports  a  severe  case  of  poisoning  following  an  injection  into 
the  bladder  of  2.0  cocain  in  20  c.c.  of  water,  although  five  times  this  quantity  had 
previously  been  borne  by  the  patient;  seven  days  later  1.0  cocain  in  30  c.c.  of  water 
was  used  in  the  same  manner  w^ithout  poisoning.  This  same  author  reports  a  second 
case  which  reacted  in  the  same  manner.  Bergmann  reports  a  case  in  which  severe 
cocain  poisoning  followed  the  injection  into  the  thigh  of  0.02  in  a  5  per  cent,  solution, 
although  0.05  in  5  per  cent,  solution  had  been  well  tolerated  the  day  before.     Hobbs 


LOCAL  ANESrilETIC  AGENTS  91 

and  Uieke  make  similar  reports  regarding  the  anesthetizing  of  nasal  nuieous  mem- 
branes, and  Ilobbs  is  therefore  of  the  opinion  that  we  cannot  speak  of  a  toxic  or  of  a 
non-toxic  cocain  dose,  since  the  same  persons  will  react  differently  to  like  doses 
of  cocain  at  different  times.  On  the  other  hand,  very  few  cases  have  been  reported 
in  Avhich  there  is  a  permanent  hypersiisceptibility  to  cocain.  It  is  not  at  all  neces- 
sary in  order  to  explain  all  these  phenomena  to  assume  an  idiosyncrasy  toward  the 
drug.  The  typical  and  regular  action  of  cocain  is  noticed  only  after  intravenous 
injections.  Extremely  small  quantities  of  a  concentrated  solution  are  sufficient  to 
severely  injure  the  central  nervous  system.  The  more  dilute  the  solutions  used  in 
this  manner  the  larger  the  dose  necessary  to  produce  the  same  toxic  symptoms. 

]\Iuch  larger  doses  of  a  concentrated  cocain  solution  can  be  applied  to  mucous 
membranes,  and  injected  subcutaneously  than  can  be  injected  intravenously,  as 
its  absorption  is  delayed,  causing  the  cocain  reaching  the  central  nervous  system  to 
become  more  dilute,  thus  preventing  symptoms  of  poisoning.  Should  a  small  quantity 
of  a  concentrated  solution  find  its  way  into  a  blood  or  lymph  vessel  or  be  very  rapidly 
absorbed  owing  to  the  nature  of  the  part  injected,  then  relatively  small  doses  act  as 
though  injected  intravenously.  In  this  manner  the  affinity  of  cocain  for  protoplasm 
can  be  explained,  as  well  as  its  local  anesthetic  properties,  which  before  the  discovery 
of  the  drug  was  never  observed  in  connection  with  any  other  substance.  This  also 
explains  its  general  action,  the  difference  in  toxicity  between  concentrated  and  dilute 
solutions,  and  the  apparent  irregularity  of  like  doses  when  injected  intravenously 
and  subcutaneously.  In  order  to  understand  local  and  general  cocain  poisoning  it 
is  necessary  to  always  keep  in  mind  the  fact  that  general  and  local  poisoning  stand 
in  definite  relation  to  the  rapidity  of  absorption. 

The  Prevention  and  Treatment  of  Cocain  Poisoning. —The  Dosage  of  Cocain.— 
How  to  avoid  the  dangers  of  cocain  can  be  learned  from  a  stud}'  of  the  preced- 
ing observations  and  the  following  experiments  on  human  beings.  It  is  not  suffi- 
cient to  consider  a  certain  dose  as  the  absolute  maximum,  as  the  authorities  differ 
widely  upon  what  they  consider  a  safe  dose.  The  difficulties  in  this  connection  will 
be  realized  after  a  consideration  of  the  doses  recommended  by  the  following  author- 
ities: Landerer,  0.01;  Woelfler,  0.02  to  0.05;  Kocher,  0.1;  Reclus,  0.2;  Gluck,  0.2  to 
0.3.  In  the  German  pharmacopeia  0.05  is  given  as  the  maximum  dose.  These 
statements  must  be  changed,  as  reliance  upon  them  has  recently  resulted  in  severe 
poisoning  (Bergmann).  The  maximum  dose  of  cocain  is  not  0.05,  as  this  dose 
neither  protects  one  from  cocain  poisoning  nor  represents  at  all  times  the  largest 
dose  that  can  be  used  with  safety. 

The  largest  quantity  of  cocain  which  can  be  injected  directly  into  the  blood- 
stream in  concentrated  form  without  producing  symptoms  of  intoxication  should  be 
considered  the  maximum  dose.    This  quantity  will  be  found  much  smaller  than  that 


92  LOCAL  ANESTHESIA 

recommended  by  the  German  pharmacopeia  and  will  be  found  to  be  a  portion  of  a 
centigram.  This  fixed  maximum  dose  is  without  the  least  practical  value,  for  by  the 
observance  of  certain  precautionary  measures  much  larger  doses  of  cocain  can  be 
introduced  into  the  body  without  danger.  These  precautionary  measures  consist 
principally  in  preventing  a  too  rapid  absorption  of  the  drug,  so  that  the  smallest 
maximum  dose  enters  the  blood-stream  at  one  time.  Very  large  doses  of  cocain 
can  be  used  without  toxic  effect  if  introduced  gradually  into  the  body  or  if  a  too 
rapid  absorption  is  prevented;  whereas  small  doses  if  rapidly  introduced  into  the 
circulation  can  give  rise  to  symptoms  of  poisoning.  The  latter  can  be  most  readily 
avoided  by  using  very  dilute  solutions  for  anesthesia,  so  that  in  the  dilution  of 
solutions  of  cocain  we  have  the  secret  of  preventing  poisoning. 

The  necessity  of  using  very  dilute  solutions  of  cocain  for  injection  was  suggested 
by  Corning  shortly  after  the  introduction  of  this  agent.  He  demonstrated  that  anes- 
thesia could  be  produced  by  using  0.33  to  0.2  per  cent,  solutions  with  the  aid  of  the 
Esmarch  bandage.  Fraenkel  likewise  observed  that  larger  areas  could  be  anesthetized 
by  a  certain  quantity  of  cocain  if  1  instead  of  10  per  cent,  solution  was  used.  In 
the  discussion  of  Berger's  case  of  cocain  death,  at  the  Paris  Surgical  Society  (1891) 
Motty  stated  that  he  used  0.5  per  cent,  cocain  solutions  entirely  without  having  one 
serious  accident  in  thousands  of  cases  in  w'hich  it  had  been  injected.  Oberst  (Pernice) 
since  1889  used  principally  0.5  to  1  per  cent,  solutions  of  cocain,  and  the  author  who 
studied  his  methods  and  has  employed  them  almost  daily,  has  never  observed  a  case 
of  cocain  poisoning.  We  are  indebted  for  the  knowledge  of  these  principles  to  the 
efforts  of  Reclus  and  Schleich.  Reclus,  in  numerous  original  articles  and  those  of  his 
pupils  (Auber,  Fillon,  Delbose,  Legrand),  offered  the  opinion  that  cocain  poisoning 
was  due  to  an  idiosyncrasy  and  demonstrated  that  it  could  be  avoided  by  proper 
technique.  He  perfected  a  method  whereby  he  could  use  a  1  per  cent,  solution,  later 
a  0.5  per  cent,  solution,  without  the  use  of  the  Esmarch  bandage,  for  performing 
major  operations  which  were  formerly  only  possible  under  general  anesthesia. 
He  reports  over  7000  cases  to  prove  the  harmlessness  of  cocain  when  used  in  this  way. 
Ceci,  Hackenbruch,  and  many  others,  promulgated  this  teaching.  Schleich  later 
taught  that  with  even  more  dilute  (0.1  to  0.2  per  cent.)  cocain  solutions  and  with 
the  aid  of  a  special  technique  and  the  use  of  cold,  the  field  for  cocain  anesthesia 
could  be  materially  extended.  Solutions  containing  1  per  cent,  and  more  of  cocain 
should  never  be  used  for  injection. 

In  W'hat  dosage  can  dilute  solutions  be  used?  The  older  literature  only  deals  with 
cocain  poisoning  following  the  use  of  concentrated  solutions,  the  maximum  dose 
of  which,  according  to  the  experience  of  Woelfler,  should  not  exceed  0.05 

It  has  already  been  shown  that  this  supposed  maximum  dose  neither  protects 
the  patient  from  poisoning  nor  does  it  represent  the  quantity  of  cocain  which  can 


LOCAL  ANESTHETIC  AGENTS  93 

be  used  without  daugvr.  The  exi)erieuce  of  Rcn-his  with  more  thau  7()()()  patients 
seems  to  iudicate  that  if  a  0.5  to  1  per  eent.  eocain  solution  is  used,  at  least  double  the 
quantity  above  mentioned  ean  be  injected.  He  has  used  as  much  as  0.2,  and  beyond 
an  occasional  transient  excitability  has  never  experienced  serious  consequences 
since  using  the  dilute  0.5  to  1  per  cent,  solution.  Reclus  holds  that  certain  measures 
of  precaution  are  absolutely  necessary.  Cocainization  should  only  be  performed  in 
the  horizontal  position,  the  patient  to  continue  this  position  two  to  three  hours 
following  major  operations  and  twenty  minutes  after  minor  operations.  The  injection 
is  never  to  be  made  with  the  needle  stationary,  but  should  be  made  continuously  during 
its  insertion  and  withdrawal  to  avoid  injecting  a  considerable  quantity  of  eocain  into 
a  vein.  With  the  use  of  the  still  more  dilute  Schleich  solution  (0.1  to  0.2  per  cent.), 
0.1  of  eocain  can  be  used  wdthout  danger.  An  efficient  method  of  avoiding  the  too 
rapid  absorption  of  eocain  and  serious  after-efl'ects  was  described  by  Corning  in  1885. 
He  ligated  the  extremity  to  be  anesthetized.  Xo  serious  cases  of  poisoning  have 
been  reported  in  which  the  extremities  w'ere  ligated  before  injection,  and  if  the  advan- 
tage would  warrant  the  use  of  concentrated  solutions,  there  would  be  no  serious 
consequences  attending  their  use  with  this  precaution.  It  is  essential  that  the  con- 
stricting band  should  be  allowed  to  remain  at  least  half  an  hour  after  the  injection; 
or  the  method  as  recommended  by  Dumont,  Wyeth,  Barton,  and  INIattison  can  be 
used,  in  which  the  band  is  loosened  several  times  for  two  or  three  minutes  before 
entirely  remo^•ing  it,  permitting  in  this  way  a  gradual  absorption  of  the  eocain 
remaining  in  the  extremity.  For  more  definite  information  concerning  the  artificial 
production  of  anemia  and  the  prevention  of  the  too  rapid  absorption  of  eocain,  see 
Chapter  VHI.  The  same  precautions  must  be  observed  in  anesthetizing  large 
absorbent  surfaces,  as  when  injecting  the  tissues,  that  is,  the  prevention  of  the  rapid 
absorption  of  even  small  doses  of  eocain.  Anesthesia  of  the  mucous  membranes  of 
the  eye,  nose,  mouth  and  larynx  can  be  rapidly  induced  by  using  a  20  per  cent, 
eocain  solution.  We  cannot  speak  of  dosage  under  these  conditions,  but  it  is  neces- 
sary to  see  that  only  small  areas  are  anesthetized  at  one  time,  and  that  the  surplus 
solution  does  not  run  into  the  mouth,  nose,  pharynx  and  esophagus;  in  this  way 
all  danger  of  severe  eocain  poisoning  can  be  avoided.  To  expose  large  absorbent 
surfaces,  such  as  the  mucous  membrane  of  the  bladder,  urethra,  scrotal  sac,  and 
joint  cavities  to  the  action  of  concentrated  solutions  of  eocain  is  extremely  dangerous, 
as  has  been  noted  in  the  history  of  eocain  anesthesia.  This  danger  cannot  be  avoided, 
no  matter  what  quantity  of  a  solution  is  injected  into  a  body  cavity.  The  ease  of 
Berger  has  already  been  mentioned  in  which  0.35  of  eocain  in  2  per  cent,  solution 
was  injected  into  the  scrotal  sac  and  immediately  drained  oft'  again;  nevertheless 
death  promptly  followed.  We  cannot  attribute  this  unfortunate  experience  to 
the  dose  of   0.35  eocain  any  more  than  we  can    explain  similar  results  following 


94  LOCAL  ANESTHESIA 

the  injection  of  cocain  into  the  bladder  and  urethra.  In  the  latter  cases  the 
bladder  is  emptied  and  washed  out,  and  the  fluid  injected  into  the  urethra  runs  out 
of  its  own  accord.  These  accidents  would  no  doubt  have  happened  e\Q\\  if  small 
quantities  of  the  solutions  used  had  been  injected.  It  is  to  be  assumed  that  as  much 
cocain  will  be  absorbed  from  5  c.c.  of  a  5  or  10  per  cent,  solution  allowed  to  act 
for  a  certain  time  on  the  bladder  mucosa  as  will  be  absorbed  from  10  c.c.  of  the 
same  solution  allowed  to  act  for  the  same  length  of  time.  General  or  local  conditions 
(ulcer  of  the  bladder)  can  in  some  cases  cause  a  more  rapid  absorption  of  cocain 
with  consequent  symptoms  of  poisoning.  The  question,  therefore,  confronting  us 
is  not  how  large  a  dose  of  cocain  can  be  introduced  into  these  cavities  but  what 
is  the  maximum  strength  of  the  solution  to  be  used.  The  answer  to  this  question  in 
reference  to  the  body  cavities,  as  the  bladder,  scrotal  sac,  and  joint  cavities,  is  to  use 
0.1  to  0.2  per  cent,  solutions,  and  if  sufficient  time  is  allowed  for  the  action  of  this 
solution  the  resulting  anesthesia  will  equal  that  induced  by  a  10  per  cent,  solution. 
The  urethra  in  the  male  can  be  anesthetized  with  a  1  per  cent,  solution  in  a  short 
time,  but  solutions  of  this  strength  should  not  be  used  for  the  other  cavities  of  the 
body.  With  the  before-mentioned  dilute  solutions,  however,  cavities  can  be  filled 
with  any  quantity  desired,  the  absorption  in  twenty  to  thirty  minutes  being  only  a 
few  milligrams  of  cocain,  the  exact  quantity  being  impossible  of  measurement, 
and  consists  only  of  that  amount  of  cocain  which  can  difi^use  through  the  wall  of  the 
cavity.  It  is  immaterial  if  we  inject  100,  200,  300  or  more  cubic  centimeters 
of  the  solution  containing  cocain  in  the  dosage  mentioned,  as  toxic  symptoms 
will  positively  not  occur. 

It  has  been  attempted,  by  the  addition  of  various  substances,  to  localize  the  action 
of  cocain.  Stuver  suggested  the  addition  of  antipyrin  (5.0  cocain,  10.0  antipyrin,  100 
water),  Gluck  carbolic  acid,  and  Parker  resorcin.  JNIany  experiments  have  failed  to 
prove  that  the  addition  of  4  per  cent,  carbolic  acid  to  watery  solutions  of  cocain 
lessens  its  toxicity  or  increases  its  local  anesthetic  properties.  Gauthier,  Thomas,  and 
Guitton  recommend  the  addition  of  nitroglycerin  (10  drops  of  a  1  per  cent,  solution 
nitroglycerin  to  10  c.c.  of  a  1  per  cent,  cocain  solution),  expecting  by  the  dilating 
effect  of  nitroglycerin  to  counteract  the  contraction  of  the  bloodvessels  as  produced 
by  cocain.  Inasmuch  as  the  contraction  of  vessels  is  only  one  symptom  of  cocain 
poisoning  this  agent  would,  by  its  dilating  effect  on  the  vessels,  be  of  value  only  in 
those  cases  associated  with  anemia  of  the  brain.  Instead  of  adding  nitroglycerin 
regularly  to  cocain  solutions  for  its  prophylactic  action,  it  would  seem  that  the  use 
of  amyl  nitrite  in  cases  of  poisoning  would  be  better,  as  this  drug  acts  similarly  to 
nitroglycerin,  causing  dilatation  of  vessels  immediately  upon  being  breathed.  What' 
is  better  is  the  avoidance  of  anema  of  the  brain  by  keeping  the  patient  in  the 
horizontal  position. 


LOCAL  ANESTHETIC  AGENTS  95 

According  to  Woelfler  toxic  symptoms  occur  more  readily  following  injections  of 
the  face  and  scalp  than  those  of  the  trunk  and  extremities,  for  which  reason  he  con- 
siders 0.02  as  the  maximum  dose  for  injections  of  the  head  against  0.05  for  the  body. 
Animal  experiments,  as  well  as  the  collection  of  the  published  reports  of  cases  of 
cocain  poisoning,  give  no  information  on  this  question.  Reclus,  with  his  large  experi- 
ence, never  observed  this  difference  when  using  more  dilute  solutions,  and  believes 
that  the  experience  of  Woelfler  was  due  to  the  fact  that  many  operations  on  the 
head  were  performed  with  the  patient  in  the  sitting  posture. 

If,  as  has  been  mentioned,  an  idiosyncrasy  does  not  exist,  and  the  irregular 
action  of  cocain  can  be  ascribed  to  peculiarities  of  the  drug  itself,  it  cannot  be  denied 
that  the  central  nervous  system  reacts  difl'erently  to  nerve  poisons  in  different  indi- 
viduals, and  likewise  in  its  reaction  toward  cocain.  With  the  presence  of  such  an 
indefinite  susceptibility  we  cannot  formulate  rules  for  the  use  of  cocain. 

In  cases  in  which  the  use  of  concentrated  solutions  of  cocain  cannot  be  avoided, 
as  in  laryngology  and  rhinology,  the  bodily  condition  of  the  patient  must  be  taken 
into  consideration.  Intoxication  from  cocain  seems  to  eflfect  both  sexes  alike. 
According  to  Trzebicki,  children  are  less  tolerant  than  adults,  while  Felizet  regards 
children  as  particularly  tolerant  toward  cocain.  Great  care  must  be  exercised  in 
administering  cocain  to  debilitated  and  nervous  persons,  those  with  serious  heart 
lesions,  patients  weakened  by  the  loss  of  blood  or  prolonged  illness,  alcoholics,  and 
those  suffering  from  hysteria  and  epilepsy  (Lewin) .  However,  with  the  cautious  use 
of  weak  cocain  solutions  this  method  of  anesthesia  is  indicated  in  these  conditions 
to  avoid  the  use  of  general  anesthesia.  With  the  increase  in  knowledge  of  the  action 
of  cocain  this  dangerous  drug  can  be  used  very  extensively  in  surgical  operations 
without  danger  to  the  patient,  if  the  proper  rules  for  its  administration  be  observed. 
With  the  proper  prophylaxis  toxic  symptoms  on  the  part  of  the  central  nervous 
system  seldom  occur. 

As  there  is  no  known  antidote  for  cocain  our  efforts  must  be  directed  to  combating 
the  symptoms  of  poisoning.  The  head  is  placed  low  and,  according  to  the  recommen- 
dation of  Schilling,  the  patient  is  permitted  to  inhale  a  few  drops  of  amyl  nitrite,  an 
agent  which  seems  to  be  of  decided  benefit  in  the  early  stages  of  poisoning.  By  this 
means  anemia  of  the  brain  can  be  prevented,  permitting  the  central  nervous  system, 
owing  to  its  richer  blood-supply,  to  more  easily  eliminate  the  cocain.  It  is  a  matter 
of  common  observation  that  the  local  effects  of  cocain  disappear  much  more  quickly 
in  hyperemic  than  in  anemic  tissues. 

Opiates  are  necessary  for  the  control  of  convulsions.  Observations  by  Mosso  in 
animal  experiments  showed  that  convulsions  do  not  occur  if  the  animal  has  been 
benumbed  with  chloral  hydrate,  ether  or  chloroform.  These  drugs  cannot  be  used 
in  man  without  great  caution,  and  opiates  should  only  be  given  during  the  period 


96  LOCAL  ANESTHESIA 

of  excitement.  If  the  poisoning  progresses  to  the  point  of  causing  paralysis  of  the 
central  nervous  system,  narcotic  drugs  are  no  longer  antagonistic  but  act  in  the  same 
manner  as  the  poison  which  they  are  intended  to  control.  It  is,  therefore,  advisable 
to  use  a  rapidly  acting  substance  such  as  ether  inhalations  for  the  control  of  the 
convulsions,  but  its  administration  must  be  stopped  as  soon  as  it  has  accomplished 
its  purpose.  In  severe  cases  of  cocain  poisoning  it  is  most  important  to  stimulate 
the  action  of  the  heart  by  rubbing  the  skin,  by  the  administration  of  stimulants  by 
mouth  or  subcutaneously,  and  in  case  of  threatened  paralysis  of  the  respiratory 
centre  artificial  respiration  must  be  immediately  instituted. 

Legrand  reports  a  case  in  which  a  patient  was  injected  subcutaneously  with  1.0 
cocain  and  kept  alive  by  artificial  respiration  continued  for  five  consecutive  hours.  In 
poisoning  by  mouth  the  stomach  must,  of  course,  be  washed  out.  In  acute  poisoning 
following  injection  into  an  extremity,  the  latter  must  be  immediately  ligated  by  a 
rubber  tube  or  band  which  is  kept  in  place  for  about  an  hour;  in  case  the  injections 
are  made  into  other  parts  of  the  body  attempts  must  be  made  to  delay  absorption 
by  cooling  the  part  either  with  the  ether  spray  or  the  application  of  an  ice-bag. 

Local  Injury  to  the  Tissues  from  Cocain  Solutions;  the  Preparation  and  Sterilization  of 
Cocain  Solutions. — Reports  of  local  damage  to  the  tissues  from  subcutaneous  or 
submucous  injections  of  cocain  solutions  are  found  only  in  the  older  literature. 
Local  gangrene  has  been  observed  several  times  at  and  around  the  point  of  injection; 
and  local  edema  has  been  frequently  observed  (Strauss,  Bousquet,  Johnson).  These 
conditions  are  usually  ascribed  to  the  use  of  unclean  preparations,  the  presence  of 
molds,  insufficient  sterilization  of  the  solution  or  operative  field.  It  has  also  been 
observed  that  very  concentrated  solutions  irritate  the  tissues,  and  by  their  dehy- 
drating action  injure  the  tissues  more  than  when  dilute  solutions  are  used. 

Up  to  the  present  time  injury  to  the  tissues  has  never  been  observed  following  the 
injection  of  dilute  cocain  solutions.  The  use  of  0.1  to  1  per  cent,  cocain  solutions 
causes  swelling  of  the  tissues.  The  more  dilute  the  greater  the  swelling.  Injection 
of  0.1  solution  into  the  cutis  is  followed  by  a  painful  infiltrate,  an  evidence  of  tissue 
injury,  whereas  if  absorption  takes  place  no  damage  to  the  tissue  occurs.  To  prevent 
swelling  following  the  use  of  dilute  solutions  sufficient  salt  must  be  added  to  make  its 
freezing-point  the  same  as  that  of  the  blood  (  —  0.55  to  —0.56°).  The  freezing-point 
of  a  0.1  per  cent,  watery  solution  of  cocain  varies  only  rf  o  of  a  degree  from  that  of 
pure  water,  while  a  1  per  cent,  solution  freezes  at  —0.115°.  By  the  addition  of  a  0.6 
per  cent,  salt  solution  to  the  latter  and  0.8  per  cent,  solution  to  the  former  both  solu- 
tions will  become  approximately  osmotically  indifferent  and  will  not  cause  injury  to 
the  tissues  when  used.  Injury  to  the  mucous  membrane  of  the  mouth,  larynx, 
nose  and  bladder  from  the  use  of  solutions  of  cocain  has  not  been  observed.  Injury 
following  the  instillation  of  cocain  into  the  eye  will  be  described  in  Chapter  XI. 


I 


LOCAL  ANESTHETIC  AGENTS  97 

Watery  solutions  of  cocaiii  are  not  very  stable,  and  are  freciuently  contaminated 
by  the  growth  of  molds,  causing  them  to  become  cloudy.  The  more  dilute  the  solu- 
tions the  more  quickly  do  these  changes  occur.  Regarding  the  sterilization  of  watery 
solutions  it  can  be  said  that  a  single  rapid  boiling  of  a  small  quantity  of  a  solution 
is  not  followed  by  a  material  loss  of  cocain,  whereas  the  repeated  boiling  of  large 
quantities  of  the  solution  or  sterilization  in  a  steam  sterilizer  cause  a  diminution 
in  the  cocain  content  with  a  diminished  activity  of  the  solution. 

The  oprator  who  has  used  solutions  treated  in  this  manner  is  not  con^'ersant  with  the 
greater  activity  of  freshly  prepared  solutions.  To  avoid  these  changes  Tuffier  advised 
tlie  fractional  sterilization  at  a  temperature  of  60°  to  70°.  It  has  been  claimed  by 
Herissey  (Reclus)  that  w^atery  solutions  of  cocain  can  be  sterilized  in  the  autoclave 
under  pressure  (115°  to  120°)  without  change,  and  can  be  thus  preserved  for  a  long 
time  in  a  sterile  condition.  According  to  Dufour  and  Ribaut  cocain  wall  deteriorate 
when  sterilized  by  this  method  if  the  ordinary  alkaline  reacting  glass  vessels  are  used. 
It  is  more  advisable  when  preparing  cocain  solutions  to  make  them  fresh  from 
tablets  just  before  use,  we  can  then  be  certain  of  their  uniform  action.  A  simple 
procedure  for  the  preparation  of  fresh  sterile  solutions  of  cocain  has  been  suggested 
by  Mikulicz.  He  dissolves  a  definite  quantity  of  cocain  in  alcohol  in  a  sterile  glass 
flask  closed  with  cotton.  After  allowing  the  alcohol  to  evaporate,  the  residue  is 
dissolved  in  water  or  salt  solution. 

The  Use  of  Other  Cocain  Combinations  for  Local  Anesthesia — Combinations  other 
than  cocainimi  hydrochloricum  ha\'e  been  up  to  the  present  time  only  occasionally 
used  for  anesthesia.  Bignon  believed  that  the  almost  insoluble  basic  cocain  in  alka- 
line solution  produced  a  more  intense  anesthesia.  Inasmuch  as  the  acid  salts  of  cocain 
usually  contained  free  acid  it  was  necessary  to  neutralize  them  in  the  following  man- 
ner: An  excess  of  sodium  bicarbonate  was  added  to  a  solution  of  cocainum  hydrochlo- 
ricum. This  caused  a  precipitation  of  the  pure  alkaloid  which  was  held  in  a  finely 
divided  state  in  suspension.  This  "cocain  milk,"  according  to  the  reports  of  Bignon, 
possessed  the  most  intense  anesthetic  action,  but  had  to  be  freshly  prepared.  The  acid 
salts  of  cocain  as  marketed  today  are  not  acid  in  reaction  but  neutral.  The  author 
compared  the  action  of  a  1  per  cent,  watery  solution  of  muriate  of  cocain  with  a  like 
solution  of  basic  cocain  by  injecting  like  quantities  into  the  skin  and  subcutaneous 
tissues,  and  found  that  the  potency  of  "cocain  milk,"  both  in  its  action  on  the 
sensory  nerve  endings  as  well  as  its  action  by  diffusion,  was  far  behind  the  muriate 
of  cocain  in  its  anesthetic  eft'ect. 

It  was  likewise  found  that  the  duration  of  anesthesia  following  injection  of  basic 
cocain  into  the  skin  was  twelve  minutes,  while  with  the  usual  solution  it  was  double 
this  time.  If  0.2  c.c.  of  a  1  per  cent,  cocain  solution  was  injected  subcutaneously 
into  cooled  tissues,  an  extensive  area  would  become  anesthetized,  while  cocain  milk 


98  LOCAL  ANESTHESIA 

used  in  the  same  manner  never  caused  the  skin  at  the  point  of  injection  to  become 
completely  anesthetic.  ^Ye  must,  therefore,  avoid  bringing  cocain  solutions  in 
contact  with  the  alkalies. 

Tubes  of  ethyl  chloride  containing  1  to  5  per  cent,  of  the  readily  soluble  alkaloid 
have  been  placed  on  the  market  (Bolognesi,  Touchard,  Legrand).  If  a  stream  of 
this  fluid  is  allowed  to  play  upon  the  mucous  membrane  of  the  lip  until  frozen,  it 
will  be  observed  upon  thawing  that  sensation  returns  and  the  mucous  membrane 
has  become  markedly  hyperemic.  About  five  minutes  later  a  gradual  and  very  intense 
anesthesia  of  long  duration  will  occur  (cocain  anesthesia).  This  intensity  is  due  to 
the  application  of  finely  divided  cocain  crystals  left  after  evaporation  of  the  ethyl 
chloride.  This  latter  agent  at  the  same  time  causes  a  delay  of  absorption  by  the  chill- 
ing of  the  tissues.  These  observations  upon  the  action  of  cocain  ethyl  chloride 
offer  an  incentive  for  the  closer  study  of  cocain  anesthesia  in  cooled  tissues,  the 
results  of  which  will  be  described  in  another  chapter.  Bolognesi  and  Touchard  rec- 
ommend this  method  for  the  anesthesia  of  the  gums  for  extraction  of  teeth,  opening 
of  abscesses  in  the  mouth,  dilatation  of  the  anal  sphincter  for  hemorrhoids  and  fissure, 
and  when  using  the  thermocautery  on  the  glans  penis  and  vulva.  The  method 
is  also  very  useful  in  superficial  operations  on  maco'is  membranes.  It  has  never 
been  successfully  proved  that  cocain,  used  in  this  manner,  could  penetrate  the 
unbroken  skin,  as  has  been  suggested  by  Legrand.  The  cocain  ethyl  chloride  spray 
applied  to  the  skin  acts  no  differently  than  pure  ethyl  chloride.  The  anesthesia 
results  from  cold  and  not  from  cocain.  Various  cocain  salts  prepared  by  ^Nlerck 
have  been  tried,  such  as  the  salicylate,  benzoate,  nitrate,  and  hydrobromate,  but 
they  do  not  possess  any  advantages  over  the  hydrochlorate. 

Space  may  be  taken  here  for  a  few  words  in  reference  to  synthetic  cocainum  pheny- 
licum  (Merck).  This  is  not  a  chemical  combination  but  a  mixture  of  cocain  and 
pure  phenol,  and  was  obtained  by  Viau  by  melting  together  one  part  of  pure  phenol 
with  two  parts  of  cocain.  The  resulting  mixture  was  of  the  consistency  of  syrup, 
and  when  applied  to  mucous  membranes  produced  intense  local  anesthesia  without 
burning.  This  preparation  was  not  practically  applied  by  Viau,  because  he  used 
only  watery  solutions  of  cocain  with  the  addition  of  the  phenol.  This  preparation 
was  again  recommended  by  Oefele,  Veasy,  and  Kyle,  and  was  prepared  by  ]\Ierck 
according  to  the  formula  of  Oefele.  Cocainum  phenylicum  is  a  brown,  stick}^ 
mass,  partially  crystalline,  insoluble  in  water,  readily  soluble  in  castor  oil  and  alcohol. 
Alcoholic  solutions  (cocaini  phenyl  1  to  0,  alcohol,  aquae  dest.  aa  50.0)  are  not  suit- 
able for  injection,  as  their  action  is  injurious  to  the  tissues  (Reclus) ;  wheals  made  from 
this  solution  become  gangrenous.  The  cauterizing  effect  of  this  solution  is  not  due 
to  the  cocainum  phenylicum  but  to  the  presence  of  alcohol.  Oily  solutions  of  this 
substance  are  absolutely  non-irritating  and  non-cauterizing.     The  injection  of  pure 


LOCAL  ANESTHETIC  AGENTS  99 

oYwe  oil  into  the  cutis  is  painless;  if,  however,  the  oil  has  l)een  i)reviously  sterilized  by 
heat,  fatty  acids  are  set  free  and  cause  considerable  pain  on  injection.  This  oil  is 
usually  indifferent  in  its  action;  if  injected  into  the  skin  it  does  not  cause  any  diminu- 
tion of  sensibility,  and  is  gradually  absorbed  without  injuring  the  tissues.  If  cocainum 
phenylicum  is  dissolved  in  oil  its  injection  into  the  skin  is  painless  even  if  the  oil  has 
been  previously  sterilized,  and  its  absorption  takes  place  without  any  damage  to 
the  tissues. 

If  a  1  per  cent,  oily  solution  of  this  preparation  is  injected  into  the  skin  complete 
anesthesia  of  long  duration  ensues  (thirty  minutes  and  longer).  Five  to  ten  minutes 
after  the  injection  anesthesia  extends  a  considerable  distance  beyond  the  point  of 
injection.  By  the  aid  of  a  small  quantity  of  a  5  per  cent,  oily  solution  injected  sub- 
cutaneously,  a  large  area  can  be  made  anesthetic  and  the  conductivity  of  nerve 
trunks  can  be  interrupted  for  one  to  two  hours. 

It  is  important  to  know  that  these  concentrated  oily  solutions  with  their  intense 
local  anesthetic  effect  do  not  cause  toxic  symptoms  following  injection,  as  has  been 
observed  after  the  use  of  concentrated  watery  solutions  of  cocain  hydrochlorate. 
Regarding  the  comparative  toxicity  of  cocain  hydrochlorate  and  phenyl-cocain, 
Dillenz  has  noted  death  in  rabbits  following  the  subcutaneous  injection  of  0.08  cocain 
hydrochlorate,  while  the  same  animals  injected  with  0.3  phenyl-cocain  in  oil  had 
only  mild  toxic  symptoms,  and  death  did  not  occur  after  the  injection  of  0.6.  Unfor- 
tunately the  concentration  of  the  solution  was  not  mentioned.  Dillenz  also  reported 
comparative  experiments  in  the  painless  extraction  of  teeth  following  the  subgingival 
injection  of  watery  solutions  of  cocain  and  solutions  of  phenyl-cocain  in  oil.  He 
found  that  dilute  solutions  of  the  hydrochlorate  did  not  produce  the  desired  result, 
while  the  concentrated  solutions,  as  is  well  known,  frequently  gave  rise  to  toxic  symp- 
toms. The  injection  of  a  4  to  5  per  cent,  solution  of  phenyl-cocain  in  oil  always  pro- 
duced results,  and  in  about  700  injections  of  a  1  to  6  per  cent,  solution  general  toxic 
symptoms  were  never  observed.  These  statements  have  been  verified.  If  the  gimis 
are  injected  on  both  sides  of  the  tooth  with  one-quarter  of  a  syringeful  of  a  5  per  cent, 
solution  of  phenyl-cocain  in  oil,  a  painless  extraction  can  be  performed  fi\e  to  ten 
minutes  later. 

There  is  no  doubt  that  the  slight  toxic  action  of  this  remedy  is  less  dependent  upon 
the  phenol  than  the  oily  solvent.  This  can  be  explained  by  the  fact  that  watery  solu- 
tions injected  under  the  skin  are  rapidly  absorbed  by  the  blood-stream,  whereas  oily 
solutions  are  more  slowly  taken  up  by  the  lymph  vessels.  This  same  action  will  take 
place  if  basic  cocain  is  injected  in  an  oily  solution  without  the  addition  of  phenol. 
The  use  of  oily  solutions  is  associated  with  considerable  discomfort. 


100  LOCAL  ANESTHESIA 


TROPACOCAIN. 


Giesel,  in  1891,  discovered  a  new  alkaloid  in  the  leaves  of  the  Java  coca  plant 
which  in  1892  was  synthetically  prepared  by  Liebermann  as  benzoylpseudotropein 
and  later  was  given  the  name  of  tropacocain  by  Chadbourne.  The  salt  of  the  hydro- 
chloride is  practically  the  only  one  used.  It  consists  of  a  white  crystalline  powder, 
readily  soluble  in  water,  having  the  formula  CsHu  NOCe  H5  CO  HCl. 

The  solutions  are  stable  and  can  be  sterilized  by  boiling.  For  the  sake  of  brevity 
tropacocainum  hydrochloricum  will  be  designated  by  the  name  tropacocain. 

The  local  and  general  physiological  action  of  this  drug  was  first  studied  by  Chad- 
bourne.  He  found  that  the  instillation  of  a  1  per  cent,  watery  solution  in  the  eye  was 
followed  in  a  few  minutes  by  a  complete  anesthesia  of  the  cornea  and  conjunctiva, 
with  only  a  slight  degree  of  mydriasis  and  no  paralysis  of  accommodation.  Anemia 
of  the  parts  did  not  occur  and  symptoms  of  irritation  were  only  noted  after  the  use 
of  a  preparation  made  from  coca  leaves,  which  was  entirely  absent  in  the  synthetic 
preparation.  Subcutaneous  injections  of  solutions  of  this  new  alkaloid  produced 
local  anesthesia,  and  Chadbourne's  reports  regarding  the  local  action  of  tropacocain 
were  soon  verified  by  many  observers.  This  agent  in  a  2  to  3  per  cent,  solution  was 
soon  recognized  as  a  useful,  non-irritating  anesthetic  for  the  eye  by  Schweigger, 
Silex,  Ferdinands,  Bockenham,  Groenouw,  Rogmann,  Veasey,  and  others.  The 
absence  of  paralysis  of  the  pupil  and  accommodation  was  considered  an  advantage 
over  cocain.  Anesthesia  occurs  very  quickly  following  its  use,  but  is  of  shorter 
duration  than  that  following  cocain;  the  anesthesia,  however,  can  be  indefinitely 
continued  by  repeated  instillations. 

For  anesthesia  of  the  pharynx,  nose,  and  larynx  this  drug,  according  to  Siefert, 
is  not  so  well  adapted,  as  the  anesthesia  may  be  insufficient  or  symptoms  of  irritation 
may  be  very  severe.  Profuse  secondary  hemorrhage  was  also  noticed  in  one  case  fol- 
lowing its  use,  but  how  this  condition  was  brought  about  by  this  agent  is  not  clear. 
According  to  reports  of  Hugenschmidt,  Pinet,  Viau,  Bauer,  Zander  and  Dillenz, 
extraction  of  teeth  can  be  painlessly  carried  out  by  the  injection  of  a  4  to  5  per  cent, 
solution  into  the  gums.  Custer  advised  this  agent  for  the  Schleich  infiltration  method, 
and  Schleich  used  the  powder  of  this  agent  for  anesthesia  of  freely  exposed  nerve 
trunks,  and  the  surface  of  serous  membranes  as  exposed  hernial  sacs. 

A  systematic  investigation  of  the  local  action  of  tropacocain  injected  into  the  skin 
has  given  the  following  results:  The  injection  of  tropacocain  dissolved  in  0.8  to 
0.9  per  cent,  salt  solution  is  absolutely  painless  when  used  in  solutions  up  to  2  per 
cent.  Stronger  solutions  cause  irritation  of  short  duration  just  as  solutions  of  cocain. 
Pure  watery  solutions  of  0.08  per  cent,  and  less  produce  pain  owing  to  the  tumefaction 
from  the  water.    The  freezing-point  of  watery  solutions  of  tropacocain  are  as  follows : 


1 

J 


LOCAL  AN  EST  II  Eric   ACE  NTS  101 

3  per  cent,  solution,  frecziiig-point —0.395° 

4  per  cont.  solution,  frcozing-point —  0..540° 

5  poi- cent,  solution,  frcozinn-ijoiiit -0.()45° 

It  will  be  seen  from  this  table  that  the  physiological  concentration  of  this  agent  is 
about  4  per  cent.,  that  watery  solutions  of  a  lower  concentration  give  rise  to  the  physio- 
logical symptoms  of  tumefaction,  while  concentrated  solutions  produce  symptoms 
of  dehydration.  It  is  therefore  necessary  in  using  weak  solutions  of  tropacocain  to 
add  sufficient  salt  to  give  a  solution  of  0.6  to  0.9  per  cent.  The  wheals  produced  by 
the  endermatic  injection  of  this  solution  become  immediately  anesthethic,  and  it 
has  been  determined  that  a  solution  of  0.01  per  cent,  tropacocain  in  0.9  per  cent, 
salt  solution  possesses  marked  anesthetic  qualities.  The  wheals  produced  by  the 
injection  of  this  agent  react  differently  than  those  produced  by  cocain.  As  a  proof  of 
this  the  author  injected  into  the  skin  a  0.1  per  cent,  solution  of  cocain  and  a  0.1  per 
cent,  solution  of  tropacocain  in  salt  solution  in  such  a  manner  that  wheals  of  the  same 
size  are  next  to  one  another.  Both  become  immediately  anesthetic,  but  the  duration 
of  the  anesthetic  from  the  tropacocain  is  less  than  half  as  long  as  that  from  cocain. 
It  will  be  found  necessary  to  use  a  tropacocain  solution  of  5  to  8  times  the  strength  of 
that  of  cocain  in  order  to  produce  an  anesthesia  of  the  same  duration.  It  can 
therefore  be  said  that  the  action  of  tropacocain  compared  with  cocain  is  much  less 
intense.  It  has  also  been  observed  that  a  few  minutes  after  the  injection  the  wheal 
produced  by  tropacocain  presents  an  entirely  different  appearance  from  that  of  cocain. 
The  latter  appears  to  have  become  smaller  and  flatter.  The  former  is  accompanied 
by  itching  and  spreads  irregularly  in  all  directions,  soon  reaching  double  its  original 
size,  and  raised  above  the  surface  of  the  surrounding  skin.  The  extension  of  the 
anesthetic  area  does  not  seem  to  follow^  the  enlargement  of  the  wheal.  The  wheal 
disappears  much  later  than  that  produced  by  cocain.  Tropacocain,  therefore, 
belongs  to  that  group  of  substances  which  cause  a  secondary  edema  of  the  tissues  into 
which  they  are  injected.  This  edema  does  not  seem  to  be  much  of  a  disadvantage 
inasmuch  as  it  disappears  very  quickly.  It  has  nothing  in  common  Viiih  the 
edema  and  infiltration  as  described  by  dentists  following  injections  of  concentrated 
cocain,  tropacocain,  eucain,  and  other  solutions.  Concentrated  solutions  of  tropa- 
cocain when  injected  into  the  tissues  give  rise  to  considerable  action  at  some  distance 
from  the  point  of  injection,  and  differ  only  from  those  of  cocain  in  their  shorter 
duration.  If  a  5  per  cent,  tropacocain  solution  be  injected  into  the  skin  the  tissues 
for  a  considerable  distance  around  the  border  of  the  area  infiltrated  become  insensi- 
tive for  a  short  time. 

Infiltration  of  the  subcutaneous  tissue  with  a  0.5  per  cent,  tropacocain  solution  causes 
anesthesia  of  the  overlying  skin.  Tissue  injury  following  the  subcutaneous  injection 
of  solutions  of  tropacocain  of  weak  and  medium  concentration  have  not  been  observed. 


102"    '  LOCAL  ANESTHESIA 

The  injected  solution  is  quickly  absorbed  without  leaving  any  mark  where  injected. 
The  blood  contained  in  the  area  injected  does  not  seem  to  be  materially  influenced. 

The  results  of  these  experiments  seem  to  show  that  tropacocain  can  be  used  for 
local  anesthetic  purposes  when  the  duration  of  the  anesthetia  is  of  no  moment.  The 
inferiority  of  this  agent  as  compared  with  cocain  is  shown  when  an  extensive  diffusive 
action  is  desired,  as  in  anesthetizing  mucous  membranes  by  local  applications.  It  must 
also  be  remembered  that  a  much  longer  time  and  much  more  frequent  application 
of  the  solution  is  necessary  to  produce  the  desired  result.  The  local  application  of 
tropacocain,  as  a  rule,  produces  an  anesthesia  of  too  fleeting  a  nature,  and  inasmuch 
as  it  has  not  the  property  of  causing  anemia,  it  is  unsuitable  for  use  in  rhinology  and 
laryngology.  If,  however,  certain  precautions  are  taken  to  prevent  its  rapid  absorp- 
tion, as,  for  instance  the  ligation  of  an  extremity,  then  tropacocain  becomes  equally 
as  efficient  an  anesthetic  as  cocain.  This  agent  likewise  becomes  efficient  for  opera- 
tions of  short  duration,  if  its  use  is  combined  with  the  cooling  of  the  tissues.  The 
general  toxic  action  of  tropacocain  is  very  similar  to  that  of  cocain,  producing  in 
animals  excitation  of  the  entire  central  nervous  system  with  severe  cortical  convul- 
sions which,  if  not  followed  by  death,  causes  paralysis.  Pulse  and  respiration  are 
increased  in  frequency,  temperature  is  elevated,  while  the  blood-pressure  falls.  The 
latter  is  in  direct  contrast  to  the  action  of  cocain  which  causes  the  blood-pressure  to 
increase  owing  to  its  power  of  contracting  the  bloodvessels.  The  experiences  of 
Chadbourne  are  not  convincing  in  reference  to  the  action  of  this  drug  upon  the 
vagus.  Following  the  administration  of  fatal  doses  death  occurs  from  paralysis  of 
the  respiratory  centre.  After  intravenous  injections,  even  in  small  doses,  cardiac 
paralysis  occurs  before  respiratory  paralysis.  The  rapidly  occurring  but  transitory 
action  of  tropacocain  can  be  observed  in  its  general  toxic  action.  It  is  very  remark- 
able to  observe  in  rabbits  and  guinea-pigs  how  quickly  these  animals  recover  from 
an  apparently  moribund  condition  following  the  injection  of  tropacocain.  After  the 
administration  of  this  anesthetic  the  animals  are  seized  with  the  most  severe 
convulsions,  but  in  about  ten  minutes  seem  to  have  regained  their  normal 
condition. 

The  toxicity  of  tropacocain  in  experiments  on  both  animals  and  man  seems  to  be 
considerably  less  than  that  of  cocain.  These  facts  have  likewise  been  verified  by 
Chadbourne,  Vamossy,  von  Pinet,  Viau,  Dillenz  and  Custer.  Custer  found  that  it 
was  necessary  to  inject  into  rabbits  0.08  of  tropacocain  per  kilo  in  5  per  cent,  solution 
compared  to  0.03  cocain  per  kilo  in  the  same  concentration  to  produce  severe  symp- 
toms of  poisoning,  and  he  believes  that  with  the  use  of  very  dilute  solutions  (0.1  to 
0.2  per  cent.)  it  is  possible  to  inject  a  maximum  dose  of  more  than  0.5.  Whether  this  is 
correct  can  only  be  determined  by  experiments  on  man.  The  author  injected  hundreds 
of  patients  with  0.5  per  cent,  tropacocain  solution  in  quantities  varying  from  40  to 


LOCAL  ANESTHETIC  AGENTS  103 

50  c.c.  without  observing-  the  slightest  general  toxic  action.  This  is  conclusive 
proof  that  0.2  in  ()..")  to  1  per  cent,  solutions  can  be  considered  a  ])crfectly  harmless 
dose. 

If  weaker  solutions  be  used  this  dose  can  be  materially  increased.  Definite  pre- 
cautionary measures  should  always  be  observed  for  the  prevention  of  general  poison- 
ing, the  same  as  after  the  use  of  cocain.  Too  large  a  quantity  should  not  be  injected 
into  the  circulation  at  one  time.  Highly  concentrated  solutions  of  tropacocain  should 
not  be  used  for  injection  or  for  application  to  large  absorbing  surfaces.  The  advice 
of  Reclus,  to  have  the  patient  anesthetized  with  cocain  assume  a  horizontal  posi- 
tion, is  not  necessary  in  tropacocain  anesthesia.  Serious  tropacocain  poisoning  has 
never  been  observed  in  man,  but  such  slight  secondary  symptoms  as  dizziness,  anemia, 
fainting,  tremor  of  the  extremities,  pressure  over  the  heart,  and  dryness  of  the  throat 
have  been  frequently  observed  by  dentists  following  the  injection  of  5  to  10  per  cent, 
solutions. 

Solutions  of  tropacocain  can  be  readily  sterilized  by  boiling  without  change  and 
can  be  preserved  in  this  sterile  condition  for  an  indefinite  time  without  altering  their 
stability.  In  weak,  non-sterile  solutions  molds  are  often  observed  which  may  cause 
a  partial  disintegration  of  this  alkaloid.  This  agent  has  been  used  almost  entirely 
in  lumbar  anesthesia. 

EUCAIN. 

Eucain,  so-called  by  Vinci  (but  later  knowai  as  «-eucain),  is  an  alkaloid  which  was 
synthetically  prepared  by  IMerling.  Its  chemical  constitution  and  physiological  action 
upon  living  animals  very  similar  to  that  of  cocain.  This  alkaloid,  having  the 
chemical  name  n-methyl-benzoyl-tetramethyloxy-piperidin-carboxylic-methyl  ester, 
is  only  slightly  soluble  in  water  but  readily  soluble  in  alcohol,  ether,  chloroform, 
and  benzol.  Its  hydrochloric  acid  salt  crystallizes  in  brilliant  leaves  and  plates, 
and  contains  one  molecule  of  the  water  of  crystallization  as  shown  in  the  formula, 
C19H07XO4  HCl  H2O. 

This  salt  is  soluble  up  to  10  per  cent,  in  water  of  the  room  temperature.  The  solu- 
tions can  be  sterilized  by  boiling  and  are  stable.  The  general  and  local  action  is  that 
of  an  intense  protoplasmic  poison.  Its  toxic  action  has  been  studied  on  animals  by 
Vinci,  and  has  been  found  similar  to  that  of  cocain.  Large  doses  cause  excitation 
of  the  central  nervous  system  with  tonic  and  clonic  convulsions  followed  by  paralysis, 
(if  the  animal  does  not  die  in  the  stage  of  convulsions).  Death  occurs  from  respiratory 
paralysis.  This  alkaloid  seems  to  be  somewhat  less  poisonous  than  cocain,  but 
according  to  Vinci  this  difference  is  not  very  great.  If  a  5  per  cent,  eucain  solution 
be  dropped  into  the  eye  or  injected  subcutaneously  intense  local  anesthesia  w^ill 


104  LOCAL  ANESTHESIA 

follow.  These  observations  have  been  verified  by  many  authorities,  but  those  who 
have  used  eucain  practically  state  that  besides  anesthesia  this  agent  causes  very 
severe  irritation  and  hyperemia  of  the  tissues,  for  which  reason  it  is  not  a  suitable 
substitute  for  cocain  (Heinze  and  Reclus).  Combinations  of  cocain  and  eucain 
(Hackenbruch)  possess  no  material  advantages.  In  fact  eucain  is  very  seldom  used 
at  present. 

Of  much  greater  value  is  another  alkaloid,  very  similar  to  tropacocain,  which  was 
described  by  Vinci  in  1897,  being  known  as  /3-eucain,  benzoyl-vinyl-diacetonal- 
karnin.  The  previously  mentioned  preparation  of  eucain  was  styled  a-eucain.  This 
nomenclature  has  caused  a  number  of  mistakes  which  we  will  shortly  describe  (Mar- 
cinowski).  Free  basic  j3-eucain,  like  cocain  or  a-eucain  is  almost  insoluble  in  water 
but  becomes  readily  soluble  when  converted  into  a  salt  by  combining  it  with  an  acid, 
hydrochloric  acid  being  used  in  the  formation  of  this  salt,  which  gives  rise  to  the  for- 
mula C15H21NO2  HCl,  a  salt  of  much  practical  value.  For  the  sake  of  brevity  we  will 
speak  of  this  salt  as  /3-eucain.  It  is  a  white  crystalline  powder  which  dissolves  in 
water  to  about  3.5  per  cent,  at  the  room  temperature.  The  solution  is  stable  and  can 
be  sterilized  by  boiling  without  change. 

Vinci  observed  that  applications  of  a  solution  of  j8-eucain  to  the  mucous  membrane 
of  the  mouth  caused  anesthesia.  If  instilled  into  the  eye  rapid  anesthesia  of  the  cornea 
and  conjunctiva  occurred,  whereas  the  pupil  and  accommodation  were  not  affected. 
Applications  of  this  agent  always  caused  considerable  hyperemia  but  not  as  marked 
as  that  following  the  use  of  a-eucain.  Attempts  were  now  made  on  all  sides  to  replace 
cocain  by  /3-eucain  wherever  local  anesthesia  was  desired,  as  in  ophthalmology 
(Silex),  urology  (Wossidlo,  Legueu),  in  laryngology  and  rhinology,  and  also  for  injec- 
tion into  the  gums  in  dental  surgery  (Dumont,  Legrand,  Keisel,  Thiesing),  and  in 
general  surgery  (Braun,  Heinze  and  Reclus).  The  properties  of  this  agent  for  local 
use  have  been  determined  by  the  systematic  investigation  of  Heinze  and  the  author. 
The  results  following  endermatic  injections  are  almost  identical  wuth  those  of  cocain. 
The  injection  of  this  alkaloid  in  indifferent  solutions  is  absolutely  painless,  even  10 
per  cent,  solutions  (prepared  by  Worming)  causing  no  symptoms  of  irritation.  The 
lower  limit  of  activity  of  this  substance  is  similar  to  cocain,  0.005  solution  produc- 
ing definite  disturbances  of  sensation  following  its  endermatic  injection. 

When  used  in  the  same  manner  eucain  anesthesia  is  usually  of  shorter  duration 
than  cocain  anesthesia.  If  0.1  per  cent,  cocain  solution  is  injected  into  the  skin 
of  a  person  to  be  experimented  upon,  0.15  per  cent.  |8-eucain  solution  would  be 
neccessary  to  produce  anesthesia  of  like  duration.  Concentrated  solutions  (more  than 
1  per  cent.)  cause  the  tissues  to  become  anesthetic  for  a  variable  distance  beyond 
the  area  directly  infiltrated.  The  extent  of  this  diffusion  is,  how^ever,  very  much  less 
than  after  the  use  of  cocain  solution  of  the  same  strength.    This  anesthetic  is  much 


LOCAL  ANESTHETIC  AGENTS  105 

less  efficient,  and  acts  more  slowly  than  cocain  solntions  when  apjjhcd  to  nuicons 
membranes  and  nerve  trunks. 

In  osmotically  indifferent  and  fairly  concentrated  solntions  /3-eucain  does  not 
cause  tissue  injury  on  injection.  Wheals  disappear  quickly  without  leaving  an  infil- 
trate, but  concentrated  solutions  (10  per  cent.)  are  not  so  well  borne  by  the  tissues, 
painful  infiltrations  usually  remaining  after  injection.  Concentratefl  solutions  of 
cocain  and  tropacocain  act  in  the  same  manner.  The  cause  of  these  symptoms 
is  not  only  from  the  substance  injected,  but  also  from  the  physical  and  dehy- 
drating action  of  these  concentrated  solutions.  Pure  w^atery  solutions  of  /J-eucain 
are  painless  in  dilutions  as  low^  as  0.04  per  cent.,  the  anesthetic  preventing  the  pain 
of  tumefaction. 

The  freezing-point  of  various  solutions  of  /3-eucain  are  as  follows: 

1  percent,  solution,  freezing-point —0.125° 

2  per  cent,  solution,  freezing-point —0.245° 

3  per  cent,  solution,  freezing-point —  0.36   ° 

4  per  cent,  solution,  freezing-point —  0.45   ° 

It  will  thus  be  seen  that  the  physiological  concentration  of  this  agent  is  about 
5  per  cent.;  more  dilute  solutions  w^hen  used  for  injections  require  the  addition  of 
O.G  to  0.7  per  cent,  of  salt,  to  prevent  the  consequences  of  tumefaction.  Injections 
of  /S-eucain  solutions  cause  a  mild  grade  of  hyperemia  in  the  tissues.  The  results 
of  these  experiments  demonstrate  that  the  local  anesthetic  property  of  solutions 
of  /3-eucain  are  in  general  similar  to  those  of  cocain  solutions  of  slightly  weaker 
concentration.  This  agent  diffuses,  however,  much  less  extensively  than  cocain, 
but  it  can  be  made  equal  to  the  latter  in  this  respect  by  slightly  increasing  its 
concentration.  Solutions  of  3.5  per  cent,  can  be  readily  prepared  with  w^arm  water, 
and  the  salt  will  not  readily  precipitate  on  cooling.  The  intense  toxic  action  of  this 
alkaloid  upon  protoplasm  even  in  very  dilute  solutions  must  necessarily  cause  general 
symptoms  of  poisoning.  This  toxic  action  has  been  studied  by  Vinci  in  animals. 
He  observed  after  the  administration  of  large  doses  irritation  of  the  central  nervous 
system,  evidenced  by  convulsions  and  exophthalmos,  which  were,  however,  much  less 
severe  than  those  following  cocain  and  a-eucain.  Central  paralysis  was  also  noted 
following  these  symptoms.  Death  occurred  from  respiratory  paralysis,  the  heart 
continuing  to  beat  for  a  considerable  longer  time.  Besides  this  action  Vinci  noted 
paralysis  of  the  peripheral  motor  nerves  and  the  vagus  similar  to  that  following  the 
use  of  curare.  Respiration  was  increased  in  frequency  and  only  during  the  stage  of 
convulsions  was  dyspnea  noted.  During  the  stage  of  paralysis  respiration  became  very 
superficial,  and  the  pulse  slow  in  consequence  of  irritation  of  the  motor  ganglion 
of  the  heart,  the  blood-pressure  falling  in  consequence  of  vasomotor  paralysis.    The 


106  LOCAL  ANESTHESIA 

toxicity  of  this  drug  is  far  less  than  that  of  cocain.    The  fatal  dose,  according  to 
Vinci,  following  subcutaneous  or  intraperitoneal  injections  is: 

jS-eucain.  Cocain. 

Rabbits 0.40  to  0.50  0. 10  to  0. 12  per  kilo 

Guinea-pigs 0.30  to  0.35  0.05  to  0.06  per  kilo 

Dolbeau,  Schmidt,  Dumont,  and  Legrand  hold  that  the  fatal  dose  of  jS-eucain 
for  animals  is  3  to  3f  times  larger  than  that  of  cocain.  The  author's  tests  coincide 
with  these  results,  provided  that  the  concentration  of  the  cocain  and  jS-eucain 
solutions  are  about  the  same.  Concentrated  j8-eucain  solutions  are  more  toxic  than 
dilute  cocain  solutions.  The  statements  of  Dolbeau  that  jS-eucain  injected  intra- 
venously is  just  as  toxic  as  cocain  have  been  found  to  be  not  quite  correct.  In  the 
author's  experiments  the  difference  was  materially  in  favor  of  /3-eucain.  Following 
the  injection  of  0.01  cocain  in  1  per  cent,  solution  into  a  vein  in  the  ear  of  a  rabbit 
weighing  1500  grams,  very  severe,  almost  fatal,  toxic  symptoms  occurred;  whereas 
the  same  quantity  of  j8-eucain  in  like  solution,  injected  intravenously  into  the  ear  of 
a  rabbit  of  the  same  weight,  produced  no  symptoms  of  poisoning.  Just  as  in  cocain 
poisoning  the  concentration  of  /3-eucain  solutions  plays  a  most  important  part. 

A  rabbit  weighing  2900  grams  was  injected  under  the  skin  of  the  back  with  3  c.c. 
of  a  10  per  cent.  /3-eucain  solution  (about  0.1  per  kilo);  clonic  convulsions  were 
noted  in  about  five  minutes,  followed  by  paralysis  of  the  extremities;  the  animal  lay 
on  its  belly  with  extended  extremities;  after  one  and  one-half  hours  the  animal  was 
to  all  appearances  again  perfectly  normal. 

A  rabbit  weighing  2800  grams  was  injected  under  the  skin  of  the  back  with  30  c.c. 
of  a  1  per  cent.  /3-eucain  solution  (more  than  0.1  per  kilo);  a  slight  paralysis  of  the 
extremities  was  noted  after  about  fifteen  minutes  that  entirely  disappeared  after  one 
and  a  half  hours. 

A  rabbit  w^eighing  2750  grams  was  injected  under  the  skin  of  the  back  with  300 
c.c.  of  0.1  per  cent.  /3-eucain  solution  (more  than  0.1  per  kilo).  This  injection  w'as 
not  followed  by  any  toxic  symptoms. 

A  rabbit  weighing  2090  grams  was  injected  subcutaneously  with  100  c.c.  of  a  1 
per  cent.  jS-eucain  solution  (0.5  per  kilo) ;  convulsions  followed  in  a  short  time,  death 
ensuing  ten  minutes  later. 

A  rabbit  weighing  1530  grams  was  injected  subcutaneously  with  750  c.c.  of  0.1 
per  cent.  jS-eucain  solution.  This  injection  was  followed  by  mild  symptoms  of  poison- 
ing, with  convulsions  and  paresis  of  the  extremities.  The  animal  appeared  perfectly 
normal  again  in  four  hours. 

To  arrive  at  definite  conclusions  in  regard  to  this  drug,  these  experiments  must  be 
frequently  repeated.     Just  as  we  observe  with  cocain,  so  also  following  the  use  of 


LOCAL  ANESTHETIC  AGENTS  107 

eiicain  in  concentrated  solutions,  the  animal  may  at  one  time  show  no  evidences  of 
l)oison  while  at  another  it  may  show  mild  or  severe  symptoms  from  the  use  of  the  same 
dose.  Following  the  subcutaneous  injection  in  a  rabbit  weighing  2120  grams  of  0.3  per 
kilo  of  /3-eucain  in  10  per  cent,  solution,  there  was  not  the  slightest  evidence  of  subse- 
quent poisoning.  Eight  days  later  this  same  dose  was  injected  in  the  same  animal 
and  in  the  same  way,  producing  very  severe  symptoms  of  poisoning.  These  differ- 
ences of  action  from  the  same  doses  and  of  like  concentration  are  undoubtedly  due 
to  uncontrollable  variation  in  the  rapidity  of  absorption  of  the  agent.  Eucain 
poisoning,  just  as  cocain  poisoning,  can  occur  when  relatively  small  doses  are  intro- 
duced into  the  circulation  and  will  not  occur  with  relatively  large  doses  when  they 
are  prevented  from  entering  the  circulation. 

The  same  rules  must  be  observed  in  the  use  and  dosage  of  /S-eucain  as  were  con- 
sidered for  cocain.  The  maximum  dose  of  /3-eucain  for  man,  which  of  course  will 
vary  with  dilute  solutions,  can  only  be  determined  by  experiments  on  human  beings. 
It  is  certainly  much  larger  than  the  maximum  dose  of  cocain  which  can  be  borne 
without  general  toxic  symptoms.  Results  obtained  after  extensive  experiments 
would  indicate  that  a  dose  of  0.1  in  1  to  2  per  cent,  solutions  w^ould  certainly  not 
be  considered  a  large  dose  and  has  been  materially  exceeded  by  some  authorities. 
Frequently  doses  of  20  to  30  c.c.  of  a  0.5  per  cent,  solution  (  —  0.1  to  0.15)  have  been 
given,  and  300  c.c.  of  a  0.1  per  cent,  solution.  The  author  has  never  seen  a  case  of 
j3-eucain  poisoning  in  patients  and  considers  the  dose  above  mentioned  harmless. 
The  use  of  30  c.c.  of  a  10  per  cent.  jS-eucain  solution  (3  grams),  as  advised  by 
Lohmann,  cannot  be  sufficiently  deprecated,  not  only  on  account  of  the  quantity 
l)ut  on  account  of  the  danger  to  the  tissues  after  using  solutions  of  this  concentra- 
tion. It  certainly  is  unnecessary  for  us  to  again  pass  through  the  experiences  and 
injuries  which  were  produced  in  the  early  days  from  cocain  used  in  a  similar  manner. 

There  are  no  reports  in  the  literature  of  poisoning  from  /3-eucain  except  those 
following  Bier's  lumbar  injections.  The  serious  consequences  following  lumbar 
injections  are  certainly  not  entirely  due  to  the  absorption  of  the  drug  but  rather  to 
the  local  action  by  contact  of  the  injected  solution  wdth  the  central  nervous  system. 
The  negative  reports  from  the  literature  do  not  indicate  by  any  means  that  poisoning 
from  eucain  has  not  occurred.  However,  it  is  justifiable  when  using  this  agent  to 
observe  all  necessary  precautions.  Marcinow^ski,  to  whom  we  are  indebted  for  his 
interesting  studies  in  regard  to  eucain,  noticed  mild  symptoms  of  poisoning  following 
the  injection  of  a  5  per  cent.  /3-eucain  solution  into  his  own  thigh  (dosage  is  not  given). 

The  author  can  report  a  similar  personal  observation.  For  experimental  purposes 
a  nerve  trunk  of  the  forearm,  probably  the  meflian  nerve,  was  injected  with  1  c.c. 
of  3  per  cent.  /3-eucain  solution  (0.03).  In  about  five  minutes  nausea,  vertigo,  and 
a  peculiar  weight  and  weakness  of  the  extremities  occurred  which  compelled  him 


108  LOCAL  ANESTHESIA 

to  lie  down.  These  observations  were  similar  to  those  of  Marcinowski.  In  about 
fifteen  minutes  all  these  symptoms  had  disappeared.  It  is  quite  as  unjustifiable 
to  use  concentrated  solutions  of  /3-eucain  for  injection  into  the  tissues  as  con- 
centrated solutions  of  cocain,  and  the  operator  must  so  perfect  his  technique  that 
it  will  not  be  necessary  to  use  highly  concentrated  solutions.  It  is  never  advisable 
to  exceed  a  2  per  cent.  jS-eucain  solution  for  injection.  This  solution  should  not  be 
considered  weak  but  rather  a  concentrated  one. 

To  recapitulate:  It  can  be  said  that  the  advantages  of  |S-eucain  over  cocain  are 
its  undoubted  milder  toxic  action,  its  stability,  and  the  possibility  of  sterilizing  by 
means  of  boiling.  The  disadvantages  of  this  preparation  are  less  intense  anesthetic 
action,  which  in  some  procedures  must  be  intensified  by  increasing  the  concentration 
of  the  solution,  mild  hyperemic  action.  Some  authorities  (Mikulicz)  attempt  to 
prevent  this  hyperemia  by  mixing  eucain  solutions  with  cocain. 

A  short  time  ago  a  new  eucain  salt  was  placed  on  the  market,  viz.,  eucainum 
aceticum.  This  latter  preparation  differs  from  the  hydrochlorate  salt  in  its  greater 
solubility  in  water  (33  per  cent.).  According  to  Cohn,  its  action  on  the  eye  differs 
but  slightly  from  that  of  jS-eucain  solutions;  at  any  rate,  2  per  cent,  solutions  cause 
very  uncomfortable  irritation.  The  author  tried  this  agent  on  healthy  individuals 
and  likewise  found  that  it  is  more  irritating  than  the  hydrochloride  of  |8-eucain. 
Whether  the  concentrated  solution  will  be  suitable  for  anesthesia  of  the  mucous 
membranes  appears  doubtful.  If  the  operator  desires  to  have  a  /3-eucain  salt  which 
is  readily  soluble  in  water,  it  would  be  best  to  use  lactic  acid  jS-eucain,  which  has 
recently  been  tried  out.  This  salt  does  not  differ  materially  either  in  its  irritating 
action  or  anesthetic  properties  from  the  hydrochlorate. 

HOLOCAIN. 

Holocain  was  prepared  in  1897  by  Taeuber  by  combining  molecular  quantities 
of  phenacetin  and  phenatidin.  It  belongs  to  the  group  of  the  amido  compounds 
(p-diathoxysephenyl-diphenyl-amidin).  Its  basic  compounds  are  insoluble  in  water, 
whereas  the  white  crystalline  needles  of  the  hydrochlorate  are  soluble  up  to  2.5 
per  cent,  in  this  liquid.  The  solutions  are  extremely  sensitive  toward  alkalies,  for 
which  reason  they  must  be  prepared  in  porcelain  vessels.  Solutions  of  this  drug  are 
stable  and  can  be  sterilized  in  porcelain  vessels  by  boiling  (Legrand).  Up  to  the 
present  this  remedy  has  only  been  used  in  ophthalmology  by  Guttman,  Hirschfeld, 
Denneft'e,  and  others.  Instillations  of  holocain  solutions  in  the  eye  first  cause  severe 
burning  followed  by  a  useful  anesthesia.  Following  the  endermatic  injection  severe 
irritation  precedes  anesthesia.  Holocain  does  not  possess  any  advantage  over  cocain 
and  jS-eucain,  and  on  account  of  its  toxic  action  should  be  used  with  great  care. 


LOCAL   ANESTHETIC  AGENTS  109 

Severe  convulsions  have  been  producedin  rabbits  l)y  tlie  administration  of  0.01  per 
kilo.  Ponchet  has  discarded  this  a,uent  owing  to  the  variation  of  the  product  found 
on  the  market.  Leurand  states  that  this  drua;  should  be  stricken  from  the  list  of  local 
anesthetics. 

ANESON. 

In  1S98,  under  the  trade  name  aneson  or  anesin,  1  to  2  per  cent,  watery  solutions 
of  trichlorj)seudobutylalcohol  w^ere  placed  on  the  market.  It  has  also  been  known 
under  the  name  of  acetone  chloroform  or  chloretone.  According  to  Vamossy,  acetone 
chloroform  when  administered  in  doses  of  from  0.5  to  1  gram  is  without  unpleasant 
consequences.  He  also  recommended  this  drug  for  local  anesthesia.  Impens,  on 
the  contrary,  claims  that  it  is  a  very  dangerous  hypnotic.  Aneson  is  a  clear  color- 
less solution  with  a  peculiar  moldy  odor  all  its  own.  Its  freezing-point  is  —0.118°, 
which  would  of  necessity  require  the  addition  of  salt  to  prevent  tumefaction 
following  injection.  Verified  in  part  by  communications  from  Israi,  Grosz,  Antal, 
Bilasko,  Vamossy  claims  that  aneson  both  when  applied  to  mucous  membranes  and 
injected  into  the  tissues  causes  a  local  anesthesia  equal  in  intensity  to  a  2  to  2.5  per 
cent,  cocain  solution. 

Heinze  and  the  author  ha^•e  experimented  with  this  solution  and  have  found  that 
when  injected  endermatically  it  causes  very  severe  pain,  and  the  anesthesia  which  is 
confined  to  the  wheal  lasts  only  a  few  minutes.  An  extension  of  the  anesthesia 
beyond  the  border  of  the  area  infiltrated  never  occurs.  We  were  also  unable  to  detect 
any  noticeable  effect  on  the  mucous  membranes,  and  just  as  little  eftect  on  the  nerve 
trunks,  which  refutes  the  communications  of  Moosbacher.  In  areas  of  the  skin  infil- 
trated with  aneson  the  painful  infiltrates  remain.  The  activity  of  aneson  is  almost 
completely  lost  on  boiling.  We  must,  therefore,  refute  the  statement  of  \^amossy 
that  this  agent  corresponds  to  a  2  per  cent,  cocain  solution  in  its  local  anesthetic 
action.  In  comparing  this  drug  with  cocain  it  wall  be  found  that  0.05  per  cent, 
cocain  solution  will  produce  the  same  local  anesthetic  eft'ect  as  aneson.  Rubinstein 
and  Sternberg  reached  the  same  conclusions  w^hen  using  this  drug  for  purposes  of 
infiltration.  If  100  c.c.  of  aneson  are  injected  subcutaneously  into  a  rabbit  weighing 
2700  grams,  the  rabbit  will  pass  into  a  sleep  lasting  twenty-four  hours,  a  death-like 
sleep;  pulse  and  respiration  are  for  hours  scarcely  noticeable;  the  animal  recovers 
gradually.  100  c.c.  of  0.05  per  cent,  cocain  solution  never  cause  such  general  symp- 
toms. Therefore,  aneson,  for  local  anesthetic  purposes,  should  be  placed  in  the 
obsolete  class. 

AKOIN. 

Under  the  name  of  akoin,  Trolldenier  has  included  chemical  compounds  similar 
to  holocain  (alkyl-oxyphenyl-guanidine).    The  akoin  of  commerce  is  a  hydrochloric 


no  LOCAL  ANESTHESIA 

acid  salt  of  guanidine,  its  chemical  name  being  di-p-anisyl-mono-p-phenetyl- 
guanidinchlorhydrat.  Akoin  is  a  white,  odorless,  crystalline  powder  of  bitter  taste, 
soluble  in  cold  water  up  to  6  per  cent.,  very  readily  soluble  in  alcohol.  The  solutions 
are  strongly  antiseptic.  The  experiments  of  Trolldenier,  made  upon  animals,  on 
his  own  person  and  other  healthy  persons,  demonstrated  that  this  substance  produced 
intense  anesthesia  of  long  duration.  A  solution  of  1  to  2000  produced  anesthesia  in 
the  eye  of  a  rabbit;  the  instillation  of  a  Iper  cent,  solution  caused  lack  of  sensation 
lasting  about  three-quarters  of  an  hour;  a  5  per  cent,  solution  produced  anesthesia 
lasting  twenty-four  hours.  Irritation  occurred  when  the  solutions  exceeded  1  per 
cent.  A  1  per  cent,  solution  was  sufficient  to  produce  a  useful  anesthesia  in  the 
eyes  of  horses  and  dogs,  but  was  not  so  efficient  when  used  in  the  eyes  of  human 
beings,  the  irritation  being  very  severe.  Endermatic  injections  made  on  human 
beings  with  a  0.05  per  cent,  solution  in  normal  salt  produced  an  anesthesia  lasting 
thirty-five  minutes.  When  the  solution  was  increased  to  0.1  per  cent,  anesthesia 
lasted  forty  minutes. 

Shortly  after  the  first  reports  by  Trolldenier  regarding  the  action  of  akoin  the 
author  carried  out  a  series  of  experiments  on  the  endermatic  injection  of  this  remedy 
in  healthy  individuals  and  found  that  it  produced  a  skin  anesthesia  of  unusual 
duration. 

Concentration  of  the  Solution  in  0.8  Per  Cent.  Salt  Solution  and  Duration  of  the  Anesthesia. 
5%  to  1%  0.5%       0.2%  0.1%  0.05%  0.01%         0.005%      0.0025% 

Several  hrs.  2  hrs.        1  hr.        30  to  40  min.      20  to  26  min.       10  min.  6  min.  4  min. 

The  duration  of  akoin  anesthesia  is  many  times  that  of  cocain  solutions  of  like 
concentration.  If  akoin  in  0.0005  per  cent,  is  added  to  an  indifferent  salt  solution 
disturbance  of  sensation  can  still  be  determined  in  the  wheal.  It  will  be  seen  that 
the  lower  limit  of  activity  of  this  substance  is  considerably  below  that  of  cocain. 
In  testing  the  sensation  after  the  injection  of  this  substance  another  material  differ- 
ence is  noted  from  that  of  cocain.  Although  anesthesia  occurs  instantly  in  the  skin 
at  the  point  injected,  it  requires  a  half-minute  or  longer  before  anesthesia  becomes 
complete  in  the  infiltrated  tissues.  It  will,  therefore,  be  noted  that  the  changes  brought 
about  in  the  nerve  substance  take  place  slower  but  are  of  much  longer  duration  than 
following  the  local  use  of  cocain.  The  injection  of  very  weak  akoin  solutions  gives 
rise  to  slight  pain.  Injury  to  the  tissues  has  not  been  observed  following  the  use  of 
dilute  solutions,  but  0.5  per  cent,  solutions  cause  a  painful  infiltrate  to  remain  at  the 
point  of  injection;  5  per  cent,  solutions  sometimes  cause  gangrene  of  the  wheal. 

The  anesthesia  resulting  from  the  diffusion  of  this  substance,  as  in  its  applica- 
tion to  mucous  membranes  and  in  anesthesia  of  nerve  trunks,  is  much  less  than  that 
following  the  use  of  cocain  solutions  of  the  same  concentration.    Akoin  is  a  severe 


LOCAL  ANESTHETIC  AGENTS  111 

poison  and  great  care  must  be  exercised  in  its  use.  Trolldenier  knl  large  doses  of  this 
substance  to  animals  without  noting  any  toxic  eli'ect,  for  which  reason  he  holds  that 
large  doses  can  be  likewise  injected  in  man,  but  experiments  of  this  kind  must  be 
viewed  with  more  or  less  skepticism. 

Opposing  these  experiments  are  those  of  Thiesing,  who  found  that  the  fatal  sul)- 
cutaneous  dose  of  akoin  for  rabbits  was  much  smaller  than  the  fatal  dose  of  cocain 
(0.15  cocain  in  1  per  cent,  solution,  opposed  to  0.08  akoin  in  1  per  cent,  solution). 

The  following  is  a  brief  record  of  the  author's  experiments  with  the  drug  on 
rabbits: 

1.  A  rabbit,  weighing  1220  grams;  subcutaneous  injection  under  skin  of  the  back 
of  6  c.c.  of  a  2  per  cent,  akoin  solution  (  =  0.1  per  kilo);  after  ten  minutes  paresis  of 
the  forelegs,  followed  by  paresis  of  the  hind  legs.  Complete  paralysis  and  difficult 
respiration  followed  rapidly.  These  symptoms  continued  four  hours  with  apparently 
no  interference  with  the  consciousness  of  the  animal.  The  animal  returned  quickly 
to  normal. 

2.  Rabbit,  weighing  1070  grams;  subcutaneous  injection  into  the  skin  of  the  back 
of  2.5  c.c.  of  a  2  per  cent,  akoin  solution  (  =  0.05  per  kilo);  in  about  twenty  minutes 
symptoms  same  as  above,  but  less  intense,  lasting  one  hour. 

3.  Rabbit,  weighing  2150  grams;  subcutaneous  injection  into  the  skin  of  the  back 
of  13  c.c.  of  a  2  per  cent,  akoin  solution  (  =  0.12  per  kilo);  convulsions  of  short  dura- 
tion followed  by  paralysis;  animal  was  alive  twenty-four  hours  later,  completely 
paralyzed,  and  was  killed  with  chloroform. 

4.  Rabbit,  weighing  1270  grams;. subcutaneous  injection  into  the  skin  of  the  back 
of  160  c.c.  of  a  0.1  per  cent,  akoin  in  salt  solution  (  =  0.12  per  kilo);  twenty  minutes 
later  severe  symptoms  of  poisoning,  with  paralysis  of  the  extremities.  The  animal 
was  restored  to  normal  in  about  six  hours. 

5.  Rabbit,  weighing  1800  grams;  subcutaneous  injection  into  the  skin  of  the  back 
of  270  c.c.  of  a  0.1  per  cent,  akoin  in  salt  solution  (  =  0.15  per  kilo);  very  severe 
poisoning  with  paralysis  of  all  the  muscles  of  the  body;  death  occurred  in  two  hours 
from  respiratory  paralysis. 

6.  Rabbit,  weighing  1300  grams;  subcutaneous  injection  into  the  skin  of  the  back 
of  200  c.c.  of  a  0.1  per  cent,  akoin  in  salt  solution  (  =  0.1G  per  kilo);  paresis  of  the 
extremities  in  twenty  minutes ;  in  two  hours  total  paralysis ;  no  eflfect  on  consciousness. 
Animal  was  alive  twenty  hours  later  but  completely  paralyzed  and  had  to  be  killed. 

7.  Rabbit,  weighing  1590  grams;  subcutaneous  injection  into  the  skin  of  the  back 
of  13  c.c.  of  a  0.2  per  cent,  akoin  solution  (  =  0.104  per  kilo);  after  ten  minutes 
unable  to  coordinate  the  movement  of  the  extremities;  difficult  respiration,  followed 
in  fifteen  minutes  by  convulsions  of  short  duration,  then  paralysis  with  apparently 
no  change  of  consciousness.    In  twenty  minutes  death  from  respiratory  paralysis. 

8.  Rabbit,  weighing  3040  grams;  subcutaneous  injection  into  the  skin  of  the  back 


112  LOCAL  ANESTHESIA 

of  a  2  per  cent,  akoin  solution  (  =  0.164  per  kilo);  death  followed  in  two  hours  with 
symptoms  as  above. 

9-10.  Dose  of  0.2  and  0.7  per  kilo  in  2  per  cent,  solution  was  followed  in  a  few 
minutes  by  death. 

Exact  pharmacological  experiments  with  akoin  have  not  been  carried  out,  and 
lacking  their  reports  all  that  can  be  said  is  that  this  agent  causes  a  peripheral 
paralysis  similar  to  that  following  the  use  of  curare  or  eucain,  at  least  the  above- 
mentioned  experiments  seem  to  point  this  way.  The  symptoms  of  general  akoin 
poisoning,  as  has  already  been  noted  in  connection  with  its  local  action,  are  very 
stable  and  of  considerable  intensity.  Medium-sized  doses  which  do  not  cause 
immediate  death  of  the  animal  give  rise  to  a  miserable  condition  which  continues 
unchanged  for  twenty  to  twenty-four  hours  and  necessitates  the  killing  of  the 
animal.  In  this  it  differs  from  the  effects  of  cocain,  eucain,  and  tropacocain  poison- 
ing, as  following  the  use  of  these  latter  drugs  the  symptoms  disappear  very  quickly. 
Another  point  of  interest  is  the  fact  that  the  same  dose  of  this  agent  in  either 
concentrated  or  dilute  solution  acts  the  same,  thus  differing  from  cocain  solutions. 

The  cause  of  these  symptoms  seems  to  be  clear.  The  prolonged  duration  of  the 
effects  of  the  poison  on  the  organs  seems  to  produce  the  same  effect  as  when  a  similar 
dose  of  other  poisons  is  rapidly  absorbed,  thus  giving  rise  to  a  cumulative  action  of 
the  drug.  The  experiments  have  also  shown  that  the  toxic  action  of  akoin  is 
exceptionally  severe,  certainly  not  less  than  that  following  the  use  of  cocain.  In 
consideration  of  the  miserable,  long-drawn-out  symptoms  of  akoin  poisoning  from 
which  the  animals  cannot  recover  yet  take  so  long  to  die,  it  appears  that  cocain 
is  by  far  the  least  dangerous  agent.  It  is  advisable  not  to  exceed  the  maximum 
dose  of  0.025,  as  suggested  by  Thiesing. 

Practical  use  of  akoin  w^as  first  made  by  Darier.  He  found  that  subconjunctival 
injections  of  cyanide  of  mercury,  which  w^re  usually  very  painful,  could  be  painlessly 
made  if  small  doses  of  a  1  per  cent,  akoin  solution  were  added  to  the  solution.  Cocain 
was  unsuitable  for  this  purpose  owing  to  the  short  duration  of  its  action.  The  value 
of  akoin  in  subconjunctival  injections  has  been  verified  by  many  ophthalmologists, 
(Guibert,  Carter,  Hirsch,  Etievant).  The  dentists  Senn,  Nipperdey,  Bab,  and 
Thiesing  advised  the  subgingival  injections  of  a  0.5  to  2  per  cent,  akoin  solution  for 
the  painless  extraction  of  teeth.  Bab  advised  combining  this  solution  with  that  of 
cocain,  claiming  that  the  action  of  a  0.5  per  cent,  akoin  and  0.5  per  cent,  cocain  solution 
was  as  effective  as  a  5  per  cent,  solution.  Spindler  praises  the  long-continued  action 
of  a  0.1  per  cent,  akoin  solution  for  Schleich's  infiltration  anesthesia.  The  author 
has  also  used  solutions  of  0.05  to  0.1  per  cent,  akoin  with  0.1  per  cent.  jS-eucain 
combined  wdth  the  requisite  amount  of  salt  in  various  major  operations  requiring 
considerable  time  for  their  performance. 


LOCAL  ANESTHETIC  AGENTS  113 

The  jS-eucain  was  added  to  these  sohitions  for  the  i)urp()se  of  preventing  the  pain 
following  injections  of  akoin  solution.  It  is  undoubtedly  an  advantage  to  use  an 
agent  for  purposes  of  infiltration  which  will  produce  anesthesia  lasting  several  hours. 
I'he  use  of  this  solution  has  been  of  particular  value  in  hemorrhoid  operations  in 
which  cocain  and  eucain  solutions  have  often  been  insufficient.  As  much  as  0.05  of 
akoin  has  been  used  at  one  dose  without  injury.  It  is  inadvisable  to  use  solutions 
for  injection  into  the  tissues  of  more  than  0.25  to  0.5  per  cent,  of  akoin,  as  they  will 
without  doubt  cause  injury  to  the  tissues.  In  most  cases  sufficient  anesthetic  effect 
can  be  obtained  from  other  agents  without  this  danger. 

Just  as  with  holocain,  solutions  of  akoin  are  extremely  sensitive  to  even  traces 
of  alkalies  as,  for  instance,  that  contained  in  glass,  for  which  reason  certain  precau- 
tionary measures  must  be  observed  in  preparing  these  solutions.  Only  distilled  water 
should  be  used  and  solutions  should  be  made  in  porcelain  vessels  either  with  cold  or 
lukewarm  water,  the  necessary  quantity  of  salt  being  added  last  of  all.  The  finished 
solution  can  be  sterilized  by  boiling  without  deterioration,  and  can  be  kept  in  dark 
bottles  previously  boiled  in  hydrochloric  acid  and  thoroughly  washed  with  distilled 
water.  It  is  perhaps  better  to  keep  watery  solutions  of  akoin  in  strengths  varying 
from  1  to  2  per  cent.,  diluting  them  just  before  use.  In  the  preparation  of  eucain- 
akoin  solution  take  25  parts  of  akoin  to  100  parts  of  absolute  alcohol  and  add  6 
drops  of  this  solution  to  about  0.05  to  a  0.1  per  cent,  eucain  solution  just  before  use. 

In  the  preparation  of  concentrated  akoin  solutions  (1  per  cent,  or  more)  these 
alcoholic  solutions  naturally  cannot  be  used,  as  the  diluted  solution  will  contain  too 
much  alcohol.  Syringes  and  needles  which  have  been  previously  boiled  in  soda 
solutions  must  be  carefully  washed  with  water  before  use.  Since  the  introduction 
of  suprarenin,  the  author  has  not  used  this  solution  for  local  anesthesia,  as  it  is 
preferable  to  use  solutions  of  cocain  and  suprarenin  for  long-continued  anesthesia. 

ANESTHETICS    OF    THE   ORTHOFORM   GROUP. 

(A)  Orthoform. — It  has  been  an  open  question  for  some  time  whether  it  was  necessary 
to  use  the  complete  cocain  molecule  for  the  production  of  local  anesthesia  or  if  parts 
of  this  molecule  possessed  similar  action.  Working  along  these  lines  Filehne  used  the 
alkaloid  ecgonin,  obtained  from  cocain  by  the  removal  of  its  benzoic  acid,  and  found 
it  to  be  absolutely  inactive.  He  also  tried  to  combine  the  benzol  group  with  cer- 
tain alkaloids  not  bearing  any  relation  to  cocain,  attempting  thereby  to  obtain  the 
anesthetic  properties  of  the  latter.  He  concluded  from  these  experiments  that  the 
anesthetic  properties  of  an  alkaloid  were  absolutely  dependent  upon  combining  the 
benzol  group  with  them.  Ehrlich  is  of  the  opinion  that  anesthetic  action  is  only 
associated  with  certain  bodies  of  the  cocain  group  and  only  those  in  which  the 


114  •  LOCAL  ANESTHESIA 

ecgonin  ether  has  taken  up  certahi  acid  radicals  which  might  be  termed  aiiesthe- 
siphoroiis. 

Stimulated  by  these  experiments  Einhorn  and  Heinz  concluded  from  their  inves- 
tigations that  local  anesthesia  was  brought  about  by  the  characteristic  action  of  all 
aromatic  amidooxy esters.  Of  all  these  substances  that  known  as  orthoform  possessed 
anesthetic  properties  in  the  highest  degree  (p-amido-m-oxybenzoicacidmethylester). 
This  substance  consists  of  a  white  powder  slightly  soluble  in  water,  a  property  wdiich 
is  of  decided  advantage  in  the  application  to  wounds,  ulcers,  burns,  rhagades,  excoria- 
tions, etc.,  as  a  useful  anesthetic.  It  produces  an  anesthesia  of  indefinite  duration, 
inasmuch  as  it  is  insoluble  in  the  body  fluids,  at  the  place  of  application;  it  likewise 
possesses  strong  antiseptic  qualities. 

Orthoform  exerts  its  anesthetic  qualities  only  wdien  in  contact  with  exposed  nerve 
ends,  and  remains  active  for  several  hours  or  days.  Owing  to  its  slight  solubility  it 
cannot  penetrate  the  intact  skin  or  mucous  membrane.  This  agent  is  apparently 
only  slightly  poisonous.  Heinz  was  able  to  inject  4  to  6  grams  and  administer  the 
same  quantity  internally  without  any  injurious  action.  Soulier  and  Guinard  found 
the  lethal  dose  for  dogs  when  internally  administered  to  be  1.0  per  kilo,  when 
placed  within  the  peritoneal  cavity  0.25  per  kilo.  The  toxic  symptoms  from  this 
drug  are  very  similar  to  those  of  cocain. 

As  a  local  anesthetic  in  surgery,  orthoform  is  of  practical  use  owing  to  its  slight 
solubility  and  the  fact  that  it  readily  undergoes  decomposition  (Heinze).  It  has 
been  recommended  by  Klaussner  and  Neumeyer  as  a  pain-relieving  application  either 
in  powder  form  or  as  a  salve  for  open  wounds,  burns,  ulcers  of  the  stomach,  for  the 
relief  of  pain  following  extraction  of  teeth,  for  pain  due  to  pulpitis,  in  painful  ulcera- 
tions of  the  leg,  decubitus,  and  carcinomatous  ulcers.  It  has  been  used  for  long 
periods  of  time  and  in  large  quantities  without  injury.  Various  secondary  effects 
have,  however,  been  noted  after  the  prolonged  use  of  this  substance  at  the  point  of 
application,  such  as  erysipelatous  reddening  of  the  skin,  swelling,  vesiculation,  local 
gangrene,  eczema,  the  latter  at  times  spreading  over  the  entire  body  (Asam,  Brocq, 
Wunderlich,  Miodowski,  Stubenrauch,  Friedlander,  Graul). 

Friedlander  collected  18  cases  in  which  general  symptoms,  such  as  vertigo  and 
vomiting,  occurred  after  the  use  of  orthoform.  There  have  also  been  unpleasant 
secondary  effects  such  as  have  been  described  following  the  use  of  this  drug  in  the 
treatment  of  leg  ulcers,  for  which  reason  this  remedy  should  be  used  with  caution, 
and  before  continuing  its  use  it  must  be  tried  on  each  individual  patient.  It  should 
never  be  used  in  cases  of  cracked  nipples  in  nursing  women  on  account  of  injury  to 
the  baby  (Pouchet).  This  same  author  also  cautions  against  the  use  of  this  remedy 
in  combination  with  silver  nitrate,  owing  to  its  strong  reducing  qualities,  nitric  acid 
being  set  free. 


LOCAL  ANESTHETIC  AGENTS  115 

(B)  New  Orthoforai. — This  remedy  is  known  under  the  high  sounding  title  of 
m-amido-p-oxybenzoicacidmethylester,  consisting  of  a  fine  powder,  cheaper  than 
orthoforni.  but  having  the  same  action  and  secondary  eft'ects  as  this  preparation. 

(C)  Nirvanin. — Owing  to  the  difficult  solubility  of  basic  orthoform  and  the  strong 
irritating  properties  from  its  acid  reaction,  this  remedy  was  not  suitable  for  local 
anesthesia  for  which  reason  Einhorn  and  Heinze  attempted  to  replace  the  amido 
atom  group  of  amidoester  and  oxyamidoester,  believing  that  this  portion  of  the 
molecule  was  of  secondary  importance  to  other  groups  of  atoms.  They  found  in  the 
hydrochloride  of  diethylglycocoll-p-amido-o-oxybenzoicacidmethylester  a  salt  readily 
soluble  in  water,  possessing  local  anesthetic  qualities,  solutions  of  which  were  neutral 
in  reaction  and  had  antiseptic  properties.  This  substance  was  given  the  name  of 
nirvanin  and  consists  of  a  wdiite  crystalline  pow^der,  solutions  of  which  are  stable 
and  can  be  sterilized  by  boiling. 

Experiments  with  nirvanin  in  0.8  per  cent,  salt  solutions  when  injected  endermat- 
ically  give  the  following  results:  The  injection  is  painful  but  is  quickly  followed  by 
anesthesia  of  the  wheal.  The  lower  limit  of  activity  of  a  solution  is  about  0.05  per 
cent,  and  can  cause  in  this  dilution  a  distinct  diminution  of  sensation.  This  is  about 
ten  times  the  concentration  of  the  weakest  cocaine  solution  which  would  be  active. 
It  was  also  found  that  to  produce  anesthesia  of  the  same  duration  it  was  necessary 
to  use  about  ten  times  the  concentration  of  a  nirvanin  solution  as  was  necessary  for 
the  cocain  solution;  for  example,  if  two  wheals  are  injected  next  to  one  another  in 
the  skin  of  a  person  to  be  experimented  upon,  one  wdth  a  0.1  per  cent,  cocain  solu- 
tion, the  other  with  a  1  per  cent,  nirvanin  solution,  the  duration  of  anesthesia  in 
both  is  about  the  same. 

Anesthesia  by  diffusion  beyond  the  borders  of  the  point  of  injection  is  not  distinctly 
shown,  even  after  the  use  of  a  5  per  cent,  solution;  at  any  rate  it  is  much  less  than  the 
diffusion  anesthesia  following  the  use  of  0.5  cocain  solution.  Injury  to  the  tissues 
has  not  been  observed  following  the  use  of  nirvanin  solutions,  it  merely  causing  a 
slight  hyperemia. 

The  experiments  following  the  practical  use  of  solutions  of  nirvanin  establish  the 
following  facts  and  results:  Anesthetic  properties  of  a  5  per  cent,  nirvanin  solution 
are  too  slight  to  replace  cocain  solutions  as  a  local  application  for  mucous  mem- 
branes. They  are  not  suitable  for  use  in  the  eye  owing  to  their  irritating  properties. 
Nirvanin  solutions  of  0.25  to  1  per  cent,  can  be  used  for  local  anesthetic  purposes. 
According  to  Luxenburger  solutions  of  2  per  cent,  nirvanin  are  suitable  for  the 
blocking  of  nerve  trunks.  The  author's  experiments  and  investigations  coincide 
with  those  of  Hoelscher.  He  found  that  the  activity  of  nirvanin  solutions  when 
injected  into  nerve  trunks  cannot  be  compared  to  cocain  solutions  of  similar  con- 
centration.    Nirvanin  solutions  of  2  to  5  per  cent,  act  more  slowly  than  0.2  to  0.5 


116  LOCAL  ANESTHESIA 

per  cent,  cocain  solutions  and  require  waiting  a  considerable  time  for  interruption 
of  nerve  conduction,  even  when  an  extremity  is  ligated.  Weaker  solutions  are  not 
at  all  active.  The  pain  associated  with  the  injection  of  nirvanin  is  extremely  unpleas- 
ant. Xirvanin  solutions  of  5  per  cent,  have  been  recommended  for  subgingival 
injections  and  extraction  of  teeth.  Rothenberger  has  used  it  in  164  cases,  and  after 
waiting  three  to  five  minutes  was  able  to  extract  teeth  without  pain  in  155  of  these 
cases.  Stubenrauch  discarded  the  5  per  cent,  solution  owing  to  the  pain  following 
injection,  and  was  able  to  make  teeth  sufficiently  anesthetic  for  extraction  by  in- 
jecting a  2  per  cent,  solution.  In  cases  where  the  alveolar  process  was  very  thick 
or  where  periostitis  was  present  this  agent  was  absolutely  ineffective. 

In  regard  to  the  toxic  action  of  nirvanin  the  following  has  been  noted:  Luxen- 
burger  found  that  general  toxic  symptoms  occurred  following  the  use  of  0.22  per 
kilo  of  this  substance  in  rabbits.  Joanin  claimed  that  the  toxicity  of  cocain  compared 
to  that  of  nirvanin  is  as  1  to  7.5.  Didrichson  observed  a  cumulative  action  of  this 
drug  and  found  that  its  toxic  effects  did  not  bear  any  relation  to  body  weight. 
Large  animals  were  affected  by  small  doses  and  vice  versa.  Small  animals  were 
often  able  to  withstand  very  large  doses. 

The  toxic  symptoms  are  similar  to  all  the  other  drugs  previously  mentioned,  con- 
sisting of  excitation  followed  by  paralysis.  Large  doses  produced  very  severe 
convulsions.  Einhorn  and  Heinze  consider  0.5  as  the  maximum  dose  in  man. 
Luxenburger  considers  0.55  as  the  maximum.  Inasmuch  as  the  dosage  for  local 
anesthesia  is  ten  times  that  of  cocain,  the  advantages  of  this  remedy  must  be  con- 
sidered very  doubtful.  Luxenburger  and  others  have  used  0.5  nirvanin  in  patients 
without  noting  any  secondary  effects.  Floeckinger  observes  after  a  dose  of  0.5 
vertigo  and  nausea,  which  were  promptly  relieved  by  the  use  of  2  mg.  of  strychnin. 
Dorn  reports  a  case  in  which,  following  the  injection  of  0.75  c.c.  of  a  5  per  cent, 
nirvanin  solution,  extensor  convulsions,  headache,  vertigo,  and  ringing  in  the  ears 
occurred.  The  above  mentioned  experiments  seem  to  indicate  that  nirvanin  will 
not  have  much  of  a  future. 

Anesthesin  and  Subcutin  (Ritsert). — Another  product  of  the  orthoform  group 
has  been  devised  hy  Hitsert  and  is  sold  under  the  trade  name  of  anesfhesin.  It  is 
a  fine,  white,  crystalline,  non-hygroscopic  powder  which,  when  placed  on  the  tongue, 
gives  rise  to  a  sensation  of  numbness.  It  is  soluble  with  difficulty  in  water,  readily 
soluble  in  alcohol  and  the  fatty  oils,  and  can  be  used  as  a  salve  without  deteriorating. 
This  agent,  according  to  Binz  and  Kobert,  is  non-toxic  and  according  to  the  reports 
of  von  Noorden  and  Lengemann  can  be  used  for  anesthetic  purposes  in  the  same 
manner  as  orthoform,  relieving  pain  for  a  considerable  period  without  the  secondary 
effects  observed  following  the  use  of  orthoform.  Von  Xoorden  recommends  this 
drug  in  cases  of  ner^-ous  hyperesthesia  of  the  stomach  and  ulcus  ventriculi.     It 


J 


LOCAL   ANESrilETIV   AGENTS  117 

shoiikl  be  taken  ten  to  fifteen  minutes  before  eating,  2.")  grams  being  consifk'red  tke 
maximum  daily  dose.  Anesthesin  can  also  be  used  as  an  insufflation  and  inhalation 
in  hyperesthesia  of  the  larynx,  in  troches  for  sore  throat  and  cough  due  to  irritation 
of  the  pharynx,  in  suppositories  for  tenesmus  and  painful  hemorrhoids,  in  salve 
(10  per  cent,  ointment  with  adeps  lanaj),  for  pruritus,  in  diabetes,  etc.  Kassel  praises 
the  action  of  this  remedy  when  used  as  an  inhalation  (anesthesin  20.0,  menthol  10.0 
to  20.0,  olei  olivarum  100.0)  in  hyperesthesia  of  the  larynx.  Lengemann,  Henius 
and  Becker  recommend  the  drug  for  the  relief  of  j^ain  in  erysipelas,  burns,  and 
])ainful  granulations,  the  drug  to  be  applied  alone  or  in  combination  with  dermatol. 
Injurious  secondary  effects  have  never  been  noticed. 

Solutions  of  the  hydrochloric  salts  of  anesthesin  in  0.25  per  cent,  strength  were  used 
by  Dunbar  and  Rammstedt  for  infiltration  and  conduction  anesthesia  on  the  fingers 
with  good  results.  Ritsert  considered  the  most  suitable  preparation  of  anesthesin 
to  be  a  combination  of  anesthesin  and  paraphenolsulfoacid  which  he  called  subcutin. 
This  is  a  white  crystalline  powder,  soluble  in  water  to  1  per  cent. ;  is  stable  and  can 
be  sterilized  by  boiling.  These  solutions  are  strongly  acid  in  reaction.  According  to 
Becker  0.8  to  1  per  cent,  subcutin  solutions  are  suitable  for  infiltration  and  conduction 
anesthesia  of  the  fingers.  Experiments  show  that  by  injecting  0.8  per  cent,  sub- 
cutin in  0.7  per  cent,  salt  solution  that  the  injections  are  not  painful  and  the 
infiltrated  tissues  become  immediately  anesthetic,  the  duration  of  the  anesthesia 
being  somewhat  longer  than  that  following  the  use  of  0.1  per  cent,  cocain  solutions. 
It  was,  however,  noted  that  the  injections  of  subcutin  produced  irritation  of  the 
tissues,  painful  infiltrates  always  being  found  at  the  point  of  injection.  These  were 
occasionally  associated  with  superficial  vesiculation.  Injecting  1.5  c.c.  of  subcutin 
solution  aroimd  the  base  of  the  fourth  finger,  which  was  ligated,  required  twenty-five 
minutes  for  complete  anesthesia.  This  injection  was  followed  by  very  severe  pain 
which  prevented  any  further  investigation  in  this  regard.  Subcutin  should,  there- 
fore, be  considered  unsuitable  for  injections  into  the  tissues. 

Propsesin  and  Zykloform. — Propsesin  is  the  propylester  and  zykloform  the 
isobutylester  of  p-amidobenzoacid.  Both  substances  consist  of  a  white  crys- 
talline powder  only  slightly  soluble  in  water.  These  substances  have  been  used 
in  powder  form  for  dusting  on  painful  ulcerations  of  all  kinds,  as  a  salve  (15 
per  cent,  propsesin  salve  according  to  Stuermer  and  Lueders,  5  to  10  per  cent, 
zykloform  according  to  Straus)  for  covering  painful  ulcerations  and  rhagades  and 
internally  for  intestinal  pain  (propaesin  2  grams,  zykloform  0.2  to  0.4).  The 
unpleasant  local  effects  observed  with  orthoform  were  not  noticed  following  the 
use  of  these  remedies. 


118  LOCAL  ANESTHESIA 

STOVAIN. 

Foiirneaii,  of  Paris,  observed  that  a  number  of  substances  belonging  to  the  amido 
alcohol  group  possessed  local  anesthetic  properties.  A  derivative  of  this  group 
known  chemically  as  a-dimethylamin-jS-benzoylpentanol-chlorhydrate  was  placed 
on  the  market  by  Billon  under  the  name  of  stovain,  and  was  used  by  the  French, 
particularly  Reclus,  as  a  substitute  for  cocain. 

Stovain  crystallizes  in  small,  white,  glistening  leaves,  is  readily  soluble  in  water, 
and  can  be  sterilized  by  boiling,  but  deteriorates  at  a  temperature  of  120°.  The 
pharmacological  properties  of  this  drug  were  studied  in  experiments  on  animals 
by  Billon  and  Pouchet.  They  found  stovain  to  be  poisonous  to  the  central  nervous 
system,  the  same  as  cocain,  after  the  administration  of  toxic  doses.  In  herbivorous 
animals  general  analgesia  was  noticed  in  a  few  cases  with  other  nervous  symptoms. 
In  other  cases,  as  in  dogs  and  cats,  these  latter  symptoms  were  more  prominent, 
evidencing  themselves  by  paralysis  of  the  extremities,  incoordination  of  movements, 
and  circular  movements.  Central  tonic  and  clonic  convulsions  resulted  in  respiratory 
paralysis  and  death  either  immediately  or  after  a  comatose  state.  The  body  tem- 
perature of  guinea-pigs  was  subnormal,  while  in  dogs  and  cats  it  was  normal  or 
elevated. 

This  drug  acts  as  a  stimulant  to  the  heart  and  has  a  dilating  effect  on  the  blood- 
vessels as  stated  by  Billon.  According  to  Pouchet  the  dilatation  of  the  bloodvessels 
and  the  lowering  of  the  blood-pressure  is  soon  followed  by  normal  conditions.  4 
per  cent,  solutions  of  stovain  applied  to  freely  exposed  nerve  trunks  cause  an  inter- 
ruption of  conductivity,  but  not  so  complete  as  after  the  application  of  cocain 
(Pouche).  Laewen  has  demonstrated  that  a  5  per  cent,  stovain  solution  applied 
to  the  freely  exposed  sciatic  nerve  of  frogs,  causes  irreparable  damage  to  the  conduc- 
tivity of  the  nerve,  and  even  after  the  use  of  a  4  per  cent,  solution  he  was  able  to  prove 
that  a  return  of  conductivity  in  the  nerve  trunk  never  occurs.  The  toxicity  of 
this  new  agent  is  supposed  to  be  two  to  three  times  less  than  that  of  cocain.  Reclus 
is  the  only  one  who  has  had  extensive  experience  in  the  practical  use  of  this  drug  for 
injection  into  the  tissues.  He  used  a  0.5  to  1  per  cent,  solution  for  purposes  of  infiltra- 
tion and  states  that  0.2  to  0.3  is  without  danger  and  can  be  used  as  a  substitute  for 
cocain.  For  anesthesia  of  the  mucous  membranes  stovain  up  to  the  present  time 
has  not  been  extensively  used.  According  to  Lapersonne  the  instillation  of  0.5  to  2.5 
per  cent,  solutions  into  the  conjunctival  sac  is  painful  and  the  resulting  anesthesia 
is  not  so  complete  nor  of  so  long  duration  as  cocain  anesthesia. 

The  author  has  tested  the  action  of  this  drug  upon  himself  and  other  healthy 
persons  by  injecting  solutions  into  the  cutis  and  subcutaneous  tissues.  The  results 
were  as  follows:    0.1  per   cent,   solution  with  the  addition  of  0.8  per  cent,  salt, 


LOCAL   ANESTHETIC   ACENTS  119 

intracutaneous  injection  of  the  forearm;  injection  was  painful.  'I'lie  wiieal  l)e('aine 
inunediateiy  an(>sthetic;  duration  of  anesthesia  five  or  six  minutes.  Hyperemia 
foiK)\vc(l  at  the  point  of  injection.  The  duration  of  anesthesia  of  a  neighboring 
wheal  made  with  0.1  ])er  cent,  cocain  solution  lasted  fifteen  minutes. 

One  })er  cent,  solution  with  the  addition  of  0.6  per  cent.  salt.  Injection  was 
^•ery  painful;  very  marked  and  lasting  hyperemia  at  the  point  of  injection;  duration 
of  anesthesia  eight  minutes.  Duration  of  anesthesia  in  the  neighboring  wheal  made 
with  1  per  cent,  cocain  solution  was  about  twenty-four  miiuites.  No  marked 
evidences  of  tissue  injury,  but  the  disappearance  of  the  wheal  was  not  so  free  from 
reaction  as  that  produced  by  cocain. 

Five  and  10  per  cent,  stovain  solutions,  subcutaneously  injected.  Injection  ex- 
tremely painful.  The  resulting  wheal  anesthesia  did  not  disappear,  and  the  entire 
wheal  as  far  as  the  subcutaneous  connective  tissue  became  gangrenous. 

The  subcutaneous  injection  of  1  per  cent,  stovain  solutions  in  the  forearm  and  neigh- 
borhood of  the  radial  nerve  produced  a  distinct  eftect  upon  the  peripheral  branches 
of  this  nerve.  Stovain  is  not  to  be  compared  in  efficiency  with  cocain,  eucain,  or 
tropacocain  solutions  of  the  same  strength.  The  injection  of  stovain  solutions  in  a 
ligated  finger  produces  the  same  results  as  cocain  solutions  of  much  weaker  concentra- 
tion. The  finger,  how^ever,  remains  painful  and  swollen  for  several  days;  whereas 
the  injection  of  cocain,  tropacocain  or  jS-eucain  causes  no  reaction.  Stovain,  accord- 
ing to  the  author's  investigations,  even  in  1  per  cent,  solutions,  causes  injury  to  the 
tissues.  Sinclair  observed  gangrene  in  4  cases  following  the  use  of  a  2  per  cent, 
solution.  These  results  stamp  this  agent  as  unsuitable  for  local  anesthesia,  a  con- 
clusion with  W'hich  Reclus  agrees. 


This  drug  recommended  by  Impens  is  very  similar  to  stovain.  Stovain  is  the 
hydrochloric  acid  salt  of  benzoylsethyldimethylaminopropanol,  and  alypin  is  the 
hydrochloric  acid  salt  of  benzolethyltetramethyldiaminopropanol,  and  is  derived 
from  the  former  by  the  substitution  of  N(CH3)2  for  the  hydrox}'l  radical.  This 
substance  consists  of  colorless  crystals  very  readily  soluble  in  water,  forming  neutral 
solutions  which  can  be  sterilized  by  boiling.  In  regard  to  the  chemical  and  phar- 
macological properties  of  alypin  reference  is  made  to  Impens'  reports. 

Experiments  with  Alypin. — 1.  0.1  per  cent,  alypin  solution  with  addition  of  0.8 
per  cent.  salt.  Formation  of  wheal  on  the  arm  of  a  healthy  person.  Injection  is  pain- 
ful, and  the  wheal  becomes  immediately  anesthetic.  Sensation  returns  in  about 
eleven  minutes.  The  wheal  becomes  slightly  hyperemic  immediately  after  injection. 
Following  the  injection  a  markedly  hyperemic  infiltrate  remains  for  several  hours. 


120  LOCAL  ANESTHESIA 

2.  Control  experiments  with  0.1  per  cent,  cocain  solution  with  addition  of  0.8 
per  cent.  salt.  Formation  of  a  wheal  next  to  the  alypin  wheal.  Injection  is  painless 
and  the  wheal  becomes  immediately  anesthetic.  Sensation  returns  in  about  fifteen 
minutes.    The  wheal  is  anemic;  there  is  no  infiltration  or  hyperemia. 

3.  1  per  cent,  alypin  solution  with  0.8  per  cent.  salt.  The  injection  is  painful, 
The  anesthesia  lasts  about  twenty  minutes.  At  the  point  of  injection  a  painful 
infiltrate  remains  for  several  days. 

4.  Control  experiment  with  1  per  cent,  cocain  solution  with  addition  of  salt. 
Injection  is  painless,  the  anesthesia  lasting  about  twenty-five  minutes;  the  injected 
solution  is  absorbed  without  leaving  any  noticeable  effect. 

5.  5  per  cent,  alypin  solution.  Injection  is  very  painful,  the  anesthesia  which 
is  quite  extensive  around  the  wheal  lasts  about  thirty-seven  minutes;  at  the  point 
of  injection  the  epidermis  is  raised  in  the  form  of  small  vesicles.  A  superficial 
layer  of  the  cutis  became  gangrenous,  for  which  reason  the  10  per  cent,  solution 
was  not  tried  for  this  purpose. 

6.  1  per  cent,  alypin  solution.  Injection  of  1  c.c.  in  the  form  of  a  transverse 
strip  under  the  skin  of  the  forearm.  In  about  ten  minutes  there  is  a  very  pronounced 
effect  upon  the  subcutaneous  nerves  from  the  solution  resulting  in  a  marked  diminu- 
tion and  in  places  complete  loss  of  sensation  in  their  area  of  distribution.  In  about 
fifteen  minutes  sensation  returns  to  normal. 

It  was  noticed  that  this  agent,  like  stovain,  produced  marked  local  anesthetic  effects. 
The  hyperemia  following  the  injection  was  slight.  The  toxicity  of  this  agent,  accord- 
ing to  Impens,  is  less  than  that  of  cocain.  Unfortunately,  the  injection  of  alypin 
is  painful,  and  the  intracutaneous  and  subcutaneous  injection  is  frequently  accom- 
panied by  very  noticeable  tissue  injury.  The  latter,  however,  is  not  so  marked  as 
following  the  injection  of  solutions  of  stovain.  Laewen  has  demonstrated  that  nerve 
trunks  poisoned  with  a  5  per  cent,  solution  of  alypin  can  be  restored  to  normal  by 
washing  out  this  solution,  which  in  the  case  of  stovain  is  impossible.  For  these 
reasons  the  use  of  solutions  of  alypin  for  injections  is  contra-indicated,  inasmuch  as 
we  have  other  agents  without  the  local  injurious  effects.  Alypin  has  been  successfully 
used  as  an  anesthetic  for  mucous  membranes  in  rhinolaryngological  practice  (Seifert, 
Ruprecht),  and  also  in  urology  (Joseph,  Kraus,  Lucke,  Lohnstein,  Garasch).  Garasch 
in  1453  cases  of  alypin  anesthesia  observed  severe  poisoning  following  the  injection 
of  5  c.c.  of  a  2  per  cent,  and  also  a  5  per  cent,  solution  into  the  urethra.  One  and  a 
half  to  two  minutes  after  the  injection  dyspnea,  nausea,  vomiting,  vertigo,  mydriasis, 
hallucinations,  and  convulsions  occurred,  pulse  and  respiration  could  not  be  counted, 
and  only  after  energetic  efforts  at  resuscitation  for  eighteen  to  twenty-two  minutes 
did  the  patient  show  evidence  of  returning  vitality.  These  toxic  symptoms  are  very 
likely  to  occur  according  to  his  experience  in  young  debilitated  persons.     G.  Ritter 


LOCAL  ANESTHETIC  AGENTS  121 

reports  one  death  from  alypin.  A  sixteen-year-old  girl  was  given  1.5  gram  adalin, 
thirty  minutes  later  1.5  eg.  morphin  preparatory  to  a  thyroidectomy.  The  operative 
field  was  injected  with  50  c.c.  of  a  2  per  cent,  alypin  solution.  Ten  minutes  later 
the  patient  became  unconscious;  convulsions,  followed  by  respiratory  and  cardiac 
paralysis,  resulted  after  a  few  hours  in  death.  The  question  naturally  arises:  For 
what  purpose  was,  and  what  were  the  indications,  for  the  use  of  such  quantities  of  a 
drug  which  had  not  been  sufficiently  tested? 


NOVOCAIN. 

Chemical  Properties.' — The  chemical  properties  of  this  drug  were  discovered  by 
Einhorn.  This  preparation  is  a  monochlorhydrate  of  p-aminobenzoyldiethylamino- 
ethanols  with  the  graphic  formula 


NH, 

Ci 

/     \ 
HC           CH 

HC           CH 

\     / 
4C 

COO.        C2H4N   (C2H5)2 

HCl 

The  salt  crystallizes  from  alcohol  in  the  form  of  needles  which  melt  at  a  tempera- 
ture of  156°.  It  is  soluble  in  equal  quantities  of  water,  producing  a  solution  neutral 
in  reaction.  It  is  soluble  in  30  parts  of  cold  alcohol.  From  watery  solutions,  corroding 
alkaline  carbonates  of  the  free  base  are  precipitated  as  colorless,  sometimes  crystalline, 
oily  substances.  By  the  addition  of  sodium  bicarbonate  clear  watery  solutions  can 
be  made.  The  free  base  crystallizes  from  dilute  alcohol  with  two  molecules  of  the 
water  of  crystallization  from  ether  or  ligroin  it  crystallizes  in  water  free,  shining 
prisms.  The  melting-point  of  the  water-containing  base  "is  about  51°,  that  of  the 
water-free  base  about  58  to  60°.  With  the  general  alkaloid  reagents,  as  potas- 
sium iodide,  calcium  mercuryiodide,  picric  acid,  this  preparation  even  in  very  dilute 
solutions  is  precipitated.  Watery  solutions  of  novocain  can  be  boiled  without 
deterioration  and  can  be  kept  in  lightly-stoppered  flasks  for  days  without  change 
of  color.     The  physiological  concentration  is  about  5.48  per  cent. 

The  pharmacological  experiments  as  carried  out  by  Biberfeld  ha\e  gi\en  the  fol- 
lowing results:  In  animals  it  was  found  that  the  preparation  anesthetizes  well  and 
very  promptly,  0.25  per  cent,  solutions  being  sufficient  to  cause  an  anesthesia  of  ten 

1  From  the  Hocchstcr  Farl)\v(-rk(>ii. 


122  LOCAL  ANESTHESIA 

minutes  in  a  freely  exposed  nerve.  When  used  locally,  this  drug  has  no  secondary 
effects,  and  even  after  the  use  of  very  concentrated  solutions  symptoms  of  irritations 
were  not  observed.  Powdered  novocain  can  be  sprinkled  upon  fresh  wounds  in 
delicate  structures  such  as  the  cornea  without  irritation;  whereas  stovain  applied 
in  this  manner  immediately  cauterizes  the  tissues.  The  general  effect  following  the 
use  of  medium-sized  doses  is  very  slight.  Doses  of  0.15  to  0.2  per  kilo  when  intro- 
duced subcutaneously  in  rabbits  produce  scarcely  any  noticeable  change  in  the 
curves  for  blood-pressure  and  respiration  on  the  revolving  tambour.  If  novocain 
is  injected  intravenously,  the  blood-pressure  sinks  and  the  respiration  becomes  slow 
and  superficial.  The  fall  of  blood-pressure  is  apparently  due  to  the  influence  of  the 
substance  upon  the  vasomotor  centres.  The  heart  does  not  seem  to  be  affected  and 
likewise  no  peripheral  action  upon  the  vessels  is  noted.  The  toxic  action  of  this 
drug  is  less  than  from  any  hitherto  known  anesthetic  substance. 

Fatal  doses  per  kilo  of  body  weight  following  subcutaneous  injections  are  as  follows: 

Cocain.  Stovain.  Novocain. 

Rabbits 0.05  to  0.1  0.15  to  0.17  O..35to0.4 

Dogs 0.05to0.07  0.15  0. 25  is  not  fatal 

IntraveJious  injections. 

Cocain.  Stovain.  Novocain. 

Cats 0.018  0.025  toO. 05  0.15  not  fatal 

Laewen's  experiments  have  shown  that  the  function  of  a  nerve  trunk  paralyzed 
by  the  application  of  a  5  per  cent,  novocain  solution  returns  quickly  to  normal  after 
the  washing  out  of  the  medicament.  The  author's  experiments  have  given  the 
following  results: 

1.  0.1  per  cent,  isotonic  novocain  solution.  Formation  of  wheal  on  forearm. 
Injection  was  painless.  Wheal  became  immediately  anesthetic.  Anesthesia,  as  with 
tropacocain  was  of  ^•ery  short  duration,  after  about  three  to  five  minutes  sensation 
returned  to  normal.  No  hyperemia.  The  wheal  disappeared  without  leaving  any 
evidence  of  its  existence. 

2.  0.5  to  1  per  cent,  novocain  solution.  Injection  painless;  duration  of  anesthesia 
ten  and  fifteen  minutes  respectively.  The  wheals  disappear  without  an}"^  injury  to 
the  tissues. 

3.  5  to  10  per  cent,  novocain  solution.  Injection  of  5  per  cent,  solution  were  pain- 
less, 10  per  cent,  solution  caused  very  slight  irritation;  duration  of  anesthesia  about 
seventeen  to  twenty-seven  minutes  very  slight  hyperemia  at  the  point  of  injection; 
the  wheals  disappeared  without  any  evidence  of  infiltration  or  sensitiveness. 

4.  1  per  cent,  novocain  solution.  1  c.c.  was  injected  subcutaneously  in  the  fore- 
arm in  the  region  of  the  superficial  radial  nerve;  the  sensation  of  the  skin  immediately 


LOCAL   AXESTHETIC  AdENTS  123 

over  the  j^oint  of  injection  was  diminished  shortly  after  the  injection.  There  was  no 
noticeable  effect  upon  the  j)erii)lieral  branches  of  the  nerve. 

5.  0.5  per  cent,  novocain  solution.  Ligation  of  the  fifth  finger  with  a  rubber  l)and; 
injection  of  1  c.c.  of  solution  around  the  base  of  the  finger  in  the  subcutaneous 
connective  tissue.  In  about  11  minutes  the  finger  as  far  as  the  tip  was  completely 
anesthetized.  Five  minutes  after  the  removal  of  the  rubber  band  sensation  returned. 
The  finger  experimented  upon  showed  no  secondary  swelling  or  sensitiveness. 

It  will  be  noted  from  these  results  that  we  have  to  do  with  an  agent  having  marked 
local  anesthetic  properties,  not,  however,  having  the  same  duration  as  many  other 
similar  substances.  We  find  for  the  first  time  since  the  discovery  of  eucain  that  we 
have  in  novocain  an  anesthetic  possessing  scarcely  any  irritating  properties.  After 
the  injection  of  10  per  cent,  solutions  of  this  substance  endermatically  it  is  found  that 
they  are  absorbed  without  leaving  any  secondary  effects.  There  is  no  peripheral 
effect  on  the  bloodvessels;  this  has  also  been  observed  by  Biberfeld.  Ten  per  cent, 
solutions  cause  very  slight  irritation  with  slight  hyperemia,  just  as  any  other  concen- 
trated hyperosmotic  salt  solution  will  produce  purely  by  its  physical  properties.  In 
the  light  of  these  experiments  it  would  be  said,  very  properly,  that  novocain,  owing 
to  the  rapid  disappearance  of  its  anesthetic  effects,  could  not  compete  with  cocain. 
Laewen  has  similarly  expressed  himself.  Experience  and  experiments  have,  how- 
ever, shown  that  by  doubling  the  dose  of  novocain,  so  as  to  make  it  as  effective  as 
cocain,  and  at  the  same  time  by  adding  certain  substances,  which  will  be  described 
in  the  next  chapter  (suprarenin),  novocain  has  become  an  ideal  anesthetic  for  injec- 
tion into  the  tissues  and  has  made  the  use  of  cocain  unnecessary.  This  agent  has 
been  introduced  into  England  by  Arnold,  Struthers,  and  LeBrocq;  in  America  by 
^McArthur,  Schley,  and  others;  in  Russia  by  Spisharny.  In  France  the  school  of 
Keclus  has  given  up  stovain  and  taken  up  novocain. 

In  a  recent  communication  regarding  his  experiments  Piquand,  a  pupil  of  Reclus, 
states:  "Novocain  at  present  seems  to  be  the  local  anesthetic  of  choice.  Its  slight 
toxicity  permits  of  the  injection  of  large  doses  without  danger,  and  the  carrying 
out  of  complicated  operations  which  were  performed  with  difficulty  or  not  at  all 
with  cocain.  Though  having  marked  anesthetic  power,  it  is  neither  irritating  nor 
does  it  ha\e  any  dilating  effect  upon  the  bloodvessels.  The  only  disadvantage  of 
novocain  as  an  anesthetic  is  its  short  duration,  which,  however,  can  be  rectified  by 
the  addition  of  small  doses  of  adrenalin,  causing  the  anesthesia  to  become  more  pro- 
nounced and  of  longer  duration  without  adding  to  the  toxicity  of  the  drug." 

Piquand  also  verified  experiments  regarding  the  use  of  novocain  and  suprarenin 
made  in  1905  by  the  author  and  many  others.  The  field  of  local  anesthesia  has 
been  materially  enlarged  and  its  possibilities  in  surgery  have  been  greatly  extended. 
For  the  anesthesia  of  mucous   membranes  novocain  is   not    so    well  suited  as  it 


124  LOCAL  ANESTHESIA 

penetrates  this  structure  with  much  more  difficulty  than  cocain  and  some  other 
substances. 

It  has  already  been  mentioned  in  describing  the  work  of  Gros  that  the  bases  of 
anesthetic  substances  are  much  more  active  than  their  salts,  and  the  activity  of  the 
salts  is  greater,  the  weaker  the  acid  contained  in  them.  In  the  light  of  these 
experiments,  Laewen  conducted  practical  experiments  and  concluded  that  novocain 
bicarbonate  solutions  produce  a  more  rapid  anesthesia  and  conduction  anesthesia 
of  longer  duration  than  novocain  hydrochloride.  The  preparations  of  novocain 
phosphates  and  novocain  borates  as  used  by  Gros  in  animal  experiments  were 
found  to  have  very  strong  anesthetic  properties,  but  owing  to  the  injury  to  the 
tissues  it  was  impossible  to  use  these  substances.  It  is  impossible  to  state  the 
maximum  dose  of  novocain  any  more  than  w^e  were  able  to  state  the  maximum 
dose  of  cocain,  eucain,  and  other  similar  agents.  The  toxicity  of  this  drug  as  with 
many  others  depends  largely  upon  the  concentration  of  the  solution  and  the  method 
of  its  use. 

In  surgical  practice  the  0.5  per  cent,  and  2  per  cent,  solutions  are  the  only  ones 
used,  as  a  rule.  The  solutions  in  combination  with  suprarenin  as  recommended  for 
use  by  many  authorities  are  the  following: 

Nast-Kolb  injected  about  50  c.c.  of  a  1  per  cent,  solution,  von  Lichtenberg  50  to 
60  c.c,  Axhausen  has  used  170  c.c.  and  has  even  gone  as  high  as  200  c.c.  (2.0 
novocain),  Chaput  110  c.c.  Borchardt  has  used  150  c.c.  of  a  0.5  per  cent,  solution, 
Hesse  250  c.c.  Since  learning  the  harmlessness  of  this  agent  we  have  been  using 
more  of  the  solution,  instilling  daily  from  100  to  200  c.c.  of  a  0.5  per  cent,  solution 
in  connection  with  small  quantities  of  a  1  per  cent,  solution,  and  repeatedly  going 
as  high  as  250  c.c.  (1.25  gram). 

Secondary  effects  from  these  doses  except  occasional  \omiting  have  not  been 
observed.  However,  the  fact  that  novocain  is  a  poison  must  not  be  forgotten. 
Regarding  the  use  of  more  highly  concentrated  novocain  solutions,  Krecke  has 
injected  subcutaneously  2  c.c.  of  a  20  per  cent,  solution  without  injury.  Liebl  in 
experiments  upon  himself  injected  0.75  c.c.  of  a  10  per  cent,  solution  into  his 
thigh,  in  five  minutes  very  mild  symptoms  occurred,  consisting  of  a  sudden  peculiar 
warmth  over  the  entire  body,  particularly  in  the  region  of  the  liver,  slight  nausea 
and  vomiting  with  general  unrest;  there  was  no  change  in  the  pulse  or  color  of  the 
face.  Two  minutes  later  slight  deafness  was  noted  in  the  left  ear;  accommodation 
of  both  sides,  but  particularly  that  of  the  left,  was  only  possible  with  much  effort; 
double  vision  occurred;  thirteen  minutes  after  the  injection  there  was  a  slight 
sticking  headache  of  the  left  side.  Seven  minutes  later  paresthesia  in  the  area  of 
the  radial  nerve  ensued,  followed  in  about  one-half  hour  by  a  return  to  normal. 
Solutions  of  this  strength  must  not  to  be  used  in  surgery. 


LOCAL  ANESTHETIC  AGENTS  125 

Laewen  and  others  ha\e  observed  typical  novocain  poisoning  following  the 
injection  of  20  to  2")  c.c.  of  a  2  per  cent,  novocain  solution  into  the  sacral  canal. 
The  symptoms  consisted  of  nausea,  sweating,  anemia  of  the  face,  rapid  pulse, 
frequent  respiration,  repeated  vomiting,  a  feeling  of  oppression  and  a  haze  in  front 
of  the  eyes.  Wq  ha\e  never  noticed  any  disturbance  following  the  subcutaneous 
injection  of  2  per  cent,  solution.  These  disturbances  from  sacral  injections  can  be 
a^•oided  by  a  slow  injection  of  the  solution  (Laewen,  von  Gaza).  The  slight  toxicity 
of  no\ocain  can  be  best  illustrated  by  the  experiment  of  Laewen  on  the  nerve  trunks 
of  the  lower  extremities.  Laewen  has  injected  as  much  as  2.1  grams  novocain;  in  one 
case  the  patient  received  20  c.c.  of  a  4  per  cent,  solution,  in  another  30  c.c.  of  2 
per  cent,  solution.  He  has  also  injected  as  much  as  50  c.c.  of  a  1  per  cent,  solution 
or  larger  quantities  of  0.5  per  cent,  solution.  The  injections  were  distributed  over 
a  period  of  time,  varying  from  ten  to  fifteen  minutes.  Li  only  a  few  cases  were 
toxic  symptoms  noticed. 

Dentists  have  noted  symptoms  of  various  kinds  in  hysterical  and  nervous  persons, 
as,  for  instance,  sensory  paralysis  of  long  duration,  and  prolonged  periods  of  sleep, 
which  were  supposed  to  be  due  to  the  toxic  effect  of  novocain.  Fischer  has  critically 
reported  on  these  results.  Moeller  has  described  a  death  occurring  in  the  practice 
of  a  dentist,  Balzer,  which  was  supposed  to  be  due  to  novocain.  A  girl,  aged 
twenty-three  years,  with  periostitis  of  the  lower  jaw.  Injection  of  3  c.c.  of  a  2  per 
cent,  novocain  solution  with  the  addition  of  suprarenin.  Following  the  extraction  of 
the  tooth  patient  did  not  feel  well;  she  rested  an  hour  and  a  half,  then  stood  up  and 
talked  excitedly.  x\fter  an  hour  and  a  half  she  again  lay  down  complaining  of  dizziness; 
six  hours  after  injection  her  condition  became  worse;  eight  hours  after  the  injection 
the  patient  died  in  coma,  with  symptoms  of  cardiac  weakness.  Fischer  believes  that 
this  was  a  case  of  acute  sepsis,  but  it  could  not  be  definitely  proved.  The  author 
(with  ]Moeller)  believes  that  without  an  autopsy,  which  was  not  made  in  this  case,  that 
it  was  impossible  to  arrive  at  definite  conclusions,  but  he  stated  that  it  was  difficult 
to  conceive  of  a  death  following  the  use  of  so  small  a  quantity  of  novocain,  since  this 
agent  was  used  in  surgery  in  fairly  large  doses  without  serious  consequences.  Two 
\ery  remarkable  observations  are  reported  by  Claus.  Li  the  first  case  a  cotton  tampon 
containing  six  drops  of  a  10  per  cent,  novocain  solution  and  six  drops  of  adrenalin 
was  placed  in  the  nose  of  a  young  woman.  The  tampon  was  removed  in  about 
twenty  minutes  and  the  antrum  was  w- ashed  out.  Almost  immediately  after  this 
I^rocedure  the  patient  became  cyanotic  and  died  of  paralysis  of  the  heart.  There 
was  no  diseased  condition  found  in  any  of  the  organs  at  autopsy. 

In  a  second  case  a  woman,  aged  thirty-six  years,  had  inserted  into  the  lower  and 
middle  portion  of  the  nasal  tract  a  tampon  containing  10  per  cent,  novocain  and  supra- 
renin solution.     Besides  this  there  w'as  a  local  application  of  a  10  per  cent,  cocain 


126  LOCAL  ANESTHESIA 

solution  applied  to  the  mucous  membrane  of  the  nose.  Following  the  anesthesia 
the  antrum  was  punctured  and  inflated;  the  patient  collapsed  and  died  the  same 
evening.  Autopsy  showed  numerous  hemorrhages  into  the  heart  muscle  and  into 
the  gray  cortex  of  the  cerebrum  and  cerebellum.  It  is  difficult  to  conceive  how  Claus 
can  state  that  this  was  a  case  of  acute  novocain  poisoning,  inasmuch  as  the  severe 
symptoms  did  not  follow  the  application  of  this  agent  but  rather  occurred  following 
the  puncture  of  the  antrum.  Claus  at  the  same  time  reports  2  cases  of  a  similar 
kind  which  were  operated  upon  without  an  anesthetic,  in  one  of  which  serious 
symptoms  of  cyanosis  and  dyspnea  occurred,  and  in  the  other  apoplexy  followed 
puncture  of  the  antrum.  At  any  rate  these  observations  teach  that  the  slightest 
operative  procedure  can  be  followed  by  dangerous  complications  which  cannot  be 
attributed  to  any  one  thing  but  must  be  explained  by  a  combination  of  circumstances. 

Other  Anesthetics. — The  anesthetic  properties  of  carhoUc  acid,  which  belongs  to  the 
group  of  agents  capable  of  penetrating  the  unbroken  skin,  has  long  been  known.  Pirrie 
advocated  the  use  of  carbolic  acid  compresses  (carbolic  acid  1,  oil  6)  for  extensive 
burns,  the  pain  being  relieved  in  about  ten  minutes.  Van  der  Weyde  noted  that 
carbolic  acid  was  used  in  America  for  a  long  time  for  the  relief  of  pain  in  carious  teeth, 
and  Rae  reports  that  the  pain  of  bee-stings  could  be  immediately  relieved  by  the 
hypodermic  injection  of  carbolic  acid  (1  to  100).  Bill  and  Smith  were  the  first  to 
recommend  compresses  and  applications  of  carbolic  acid  to  the  skin  for  surgical 
purposes.  Smith  painted  the  skin  of  the  forearm  with  85  per  cent,  carbolic  acid; 
this  was  followed  in  a  few  minutes  by  burning,  after  which  the  entire  thickness  of 
the  skin  could  be  cut  without  any  sensation.  This  drug  has  also  been  used  with  suc- 
cess for  the  opening  of  superficial  felons.  It  was  observed  in  the  hospital  of  the  Rudolf 
Stiftung  in  Vienna  that  the  injection  of  1  to  3  per  cent,  carbolic  acid  gave  better  local 
anesthetic  effects  than  injections  of  morphin.  Caspari  used  a  2  per  cent,  solution  of 
carbolic  acid  subcutaneously  with  very  good  results.  Walser  was  able  to  produce 
very  decided  local  anesthetic  effects  by  the  use  of  a  spray  of  a  3  per  cent,  carbolic 
acid  solution.  Richardson  recommended  for  local  anesthesia  ether  sulphate  75.0, 
acid  carbol.  0.3  in  spray  form,  claiming  to  be  able  to  produce  a  much  more  intense 
action  than  by  the  use  of  pure  sulphuric  ether.  Schleich  also  used  on  circumscribed 
areas  of  mucous  membranes  and  on  the  freely  exposed  nerve  trunks  in  operative 
wounds  a  5  per  cent,  carbolic  acid  solution  to  a  local  anesthetic  to  cause  anesthesia 
in  these  parts.  Strongly  irritating  carbolic  acid  can  hardly  be  considered  today, 
inasmuch  as  we  possess  so  many  other  more  suitable  drugs. 

Besides  the  previously  mentioned  substances  there  are  a  number  of  other  drugs 
to  which  anesthetic  properties  are  ascribed.  Mays  found  that  with  brucin,  an 
alkaloid  similar  to  strychnine,  the  cornea  could  be  made  insensitive  following  the 
application  of  5  to  20  per  cent,  solution.    Seiss  was  able  to  verify  these  observations 


.J 


LOCAL   ANESTIfETIC   AGENTS  127 

and  used  this  drug  in  o  per  cent,  solutions  in  furuncles  of  the  auditory  canal,  in 
suppurati\e  processes  of  the  middle  ear  for  the  purpose  of  introducing  instruments 
into  the  ear.     Further  observations  in  regard  to  this  remedy  are  not  at  hand. 

Stenorarpin  or  gledUschin,  an  alkaloid  supposed  to  be  derived  from  the  gleditschia 
triacanthus,  according  to  the  investigations  of  Goodmann  and  Claiborne  acts  as  a 
mydriatic  and  local  anesthetic  when  applied  to  the  eye,  Novy,  investigating  this 
drug,  proved  it  to  be  an  "industrial  humbug,"  and  that  the  supposed  2  per  cent, 
gleditschin  solution  was  a  mixture  of  cocain  chlorhydrate,  atropin  sulphate,  and 
salicylic  acid.    The  presence  of  the  alkaloid  gleditschin  was  not  denied. 

Local  anesthetic  properties  were  also  observed  by  Steinach  and  Panas  with  siro- 
phanthin,  erythropJdein,  helleborin,  conxallarin,  adonidin,  dionin,  peronin,  and  many 
other  substances  which  are  more  or  less  impractical  owing  to  their  local  irritating 
qualities  and  the  damage  to  the  tissues,  and,  in  case  of  some  of  them,  to  their 
general  toxic  symptoms.  Erythrolphlsein  was  tested  practically  in  1888  and  caused 
Liebreich  to  give  expression  to  the  paradox,  "anesthetica  dolorosa."  Guaiacol  was 
recommended  by  L.  Championniere  as  a  local  anesthetic,  but  owing  to  its  severe  irri- 
tating properties  and  the  fact  that  it  causes  gangrene  of  the  tissues,  it  is  unsuitable 
for  local  anesthesia  (Reclus). 

Antipyrm  solutions,  which  according  to  the  investigations  of  Heinze  are  not  suitable 
for  injection  into  the  tissues,  were  used  by  Lydston  for  anesthetizing  the  mucous 
membrane  of  the  bladder  and  urethra  (10  per  cent,  antipyrin  with  addition  of  1  per 
cent,  carbolic  acid).  Kocher  used  for  anesthesia  of  the  larynx  a  solution  of  5  per 
cent,  cocain  with  5  per  cent,  antipyrin  and  1  per  cent,  carbolic  acid.  Ephraim  advised 
the  use  of  2  per  cent,  antipyrin  and  1  per  cent,  solution  of  chinin  bimuriatic  carbamid 
for  anesthesia  of  the  mucous  membrane  of  the  upper  air  passages. 

In  more  recent  times,  Dalma  prepared  an  alkaloid  from  the  Indian  plant  gasu- 
hasu  and  named  it  nerrozidin,  which  was  supposed  to  possess  very  marked  local 
anesthetic  properties.  Magnani  found  that  the  alkaloid  yohimhin,  derived  from 
yohimbehe-bark,  produced  anesthesia  of  the  cornea  and  conjunctiva  when  instilled 
into  the  eye.  Loewy  and  IMoeller  investigated  this  remedy  more  closely,  and  found 
that  a  1  per  cent,  solution  interrupted  the  conductivity  of  motor  and  sensory  nerve 
tracts  (sciatic  and  vagus).  Just  as  with  cocain  the  sensory  nerves  were  interrupted 
before  the  motor  nerves.  The  action  of  this  drug  is  transitory  and  the  return  to 
normal  takes  place  rapidly.  IMarked  irritation  following  the  use  of  this  remedy 
was  not  observed.  According  to  Oberwarth,  0.05  per  kilo  injected  subcutaneously 
caused  death  in  rabbits,  and  inasmuch  as  severe  symptoms  are  produced  in  man  by 
the  use  of  5  mg.  of  this  drug,  it  must  be  used  with  great  caution.  This  drug  owes 
its  value  to  its  supposed  action  on  the  male  genital  organs,  causing  hyperemia  and 
prolonged  erections. 


128  LOCAL  ANESTHESIA 

The  value  of  the  various  substitutes  for  cocain  can  be  judged  from  the  following 
resume.  The  requirements  of  local  anesthetics  are  as  follows:  1.  The  substance 
must  be  less  toxic  than  cocain  in  proportion  to  its  local  anesthetic  power.  The  deter- 
mination of  a  lessened  toxicity  is  not  sufficient,  for  if  its  anesthetic  property  be  less 
than  cocain  proportionately  larger  doses  will  be  necessary  to  attain  the  same  results 
as  with  the  latter  drug;  all  known  substitutes,  with  the  exception  of  akoin,  fulfil  these 
requirements. 

2.  The  agent  must  not  cause  the  slightest  irritation  or  tissue  injury  but  must, 
like  cocain,  be  absorbed  from  the  place  of  application  without  any  secondary  effects 
such  as  severe  hyperemia,  inflammation,  painful  infiltrates,  or  necrosis.  Only  when 
these  conditions  are  fulfilled  can  we  assume  that  the  healing  of  wounds  will  not  be 
interfered  with.  The  use  of  strongly  acid  or  alkaline  reacting  substances  is  not  per- 
missible, inasmuch  as  they  cause  local  tissue  injury.  On  account  of  this  important 
requirement  many  of  the  newer  anesthetics  have  failed  in  their  purposes.  The  only 
local  anesthetics  not  causing  tissue  injury  besides  cocain  are  tropacocain,  eucain,  and 
novocain.  Several  others,  such  as  alypin,  cause  so  little  damage  to  the  tissues  that 
their  use  is  still  open  to  question  (superficial  application  to  mucous  membrane). 

3.  The  agent  must  be  soluble  in  water  and  its  solutions  stable  and  possible  of 
sterilization  by  boiling.  These  requirements  are  met  by  all  previously  mentioned 
substances,  except  cocain,  which  only  in  part  meets  the  conditions. 

4.  It  must  be  possible  to  combine  the  agent  with  suprarenin,  as  will  be  described 
in  the  next  chapter.  Cocain,  alypin,  and  novocain  meet  this  requirement,  but  all 
other  agents  interfere  to  some  extent  with  the  action  of  suprarenin. 

5.  For  particular  places  of  application,  as,  for  instance,  mucous  membranes,  the 
anesthetic  must  be  able  to  penetrate  rapidl}^,  its  anesthetic  properties  being  dependent 
upon  this  quality. 

Novocain  and  alypin  are  the  two  substances  which  have  made  the  use  of  cocain 
in  surgery  almost  obsolete.  Eucain  has  been  superseded  by  novocain,  and  the  use  of 
tropacocain  and  stovain  is  now  almost  entirely  limited  to  lumbar  anesthesia.  The 
other  substances  had  best  not  be  used  as  anesthetics  for  operative  work,  inasmuch 
as  they  all  have  disadvantages  without  possessing  any  advantages  over  those  just 
named. 


CHAPTER   VIII. 

FrUTIIEU   AIDS  TO  L(X\AL  AXP:STHESIA.     THE   IXFLUEXCE   OF 

THE   VITALITY  OF  THE   TISSUES   UPON  THE   LOCAL  AND 

TOXIC  ACTION  OF  LOCAL  AXESTHETIC  AGEXTS. 

Local  anesthetic  siil)stances  acting  npon  Viv'mg  tissues,  in  which  the  vitahty — that 
is,  chemical  and  physical  changes — is  artificially  interfered  with,  and  the  circulation  is 
disturbed,  cause  a  much  more  intense  local  anesthesia  than  in  tissues  with  undisturbed, 
active  metabolism  and  normal  circulation.  This  increase  of  local  action  is  brought 
alM)ut:  (1)  By  delaying  the  absorption  of  the  poison  from  the  point  of  appli- 
cation, thus  allowing  much  longer  time  for  local  action.  (2)  By  inhibiting  all  of 
those  processes  which  the  living  tissues  exert  against  a  foreign  substance  but  only 
to  an  extent  that  will  permit  the  tissues  to  return  to  normal  after  exerting  their  local 
effect.  With  the  increase  in  intensity  of  the  local  action  there  must  be  an  accom- 
panying diminution  in  the  general  toxicity  from  the  substance  because  (a)  the 
absorption  of  the  poison  is  delayed;  because  (6)  much  of  the  poison  is  destroyed 
locally  and  therefore  does  not  enter  the  circulation.  The  knowledge  of  substances 
which  produce  an  artificial  diminution  or  suspension  of  vitality  and  which  cause 
a  diminution  of  the  parenchymatous  absorption  is  of  much  importance  to  local 
anesthesia. 

To  a  certain  extent  the  dilute  solutions  of  Schleich  used  for  infiltration  of  the  tissues 
belong  to  this  class.  By  means  of  these  dilute  solutions  the  quantity  of  the  anesthetic 
can  be  evenly  tlivided  o^•e^  a  considerable  area  and  thus  be  more  slowly  absorbed, 
permitting  the  tissues  to  come  in  better  contact  with  the  agent  than  if  a  similar 
quantity  had  been  injected  in  more  concentrated  solution.  The  dilution  of  the  solu- 
tion decreases  both  the  toxic  and  fatal  dose  of  the  anesthetic.  It  will,  therefore,  be 
seen  that  the  dilution  of  the  solution  increases  the  local  effect  and  diminishes  the 
toxic  action  of  the  substance. 

The  rapidity  of  absorption  can  be  diminished  and  the  local  effect  increased,  together 
with  diminished  toxicity,  if  the  anesthetic  is  dissolved  in  oil  instead  of  water.  The 
absorption  of  solutions  in  oil,  which  takes  ))lace  through  the  lymphatics,  is  much 
slower  than  watery  solutions,  which  are  taken  up  directly  by  the  circulation. 
Legrand  and  Hartwig  recommend  that  gelatin  be  added  to  the  anesthetic  solutions 
used  for  injection.  This  has  likewise  been  advised  by  Klapp  to  delay  absorption. 
Contrary  to  these  recommendations  the  author  has  failed  to  note  an  increase  in  the 
local  effect  from  cocain  by  the  addition  of  gelatin.  The  solutions  were  of  course  care- 
9 


130  LOCAL  ANESTHESIA 

fully  sterilized,  which,  according  to  Klapp,  so  alters  the  gelatin  that  its  property  of 
delaying  absorption  is  lost.  On  this  account  the  practical  application  of  this  method 
cannot  be  considered.  We  possess,  however,  three  other  important  aids  to  local  anes- 
thesia which  can  be  considered  in  this  connection:  The  hindrance  or  interruption 
of  the  blood-stream  by  means  of  ligating  the  extremities,  the  use  of  a  substance  causing 
a  contraction  of  the  bloodvessels  (suprarenin),  and  the  cooling  of  the  tissues  by  means 
of  the  ether  or  ethyl  chloride  spray  after  the  injection  of  the  local  anesthetic.  We 
will  consider  these  methods  in  the  order  named. 


THE   EFFECTS    OF   MECHANICAL   INTERRUPTION  OF    THE    CIRCULATION 
ON   LOCAL   AND    GENERAL   POISONING. 

If  a  small  quantity  of  a  watery  solution  of  coloring  matter,  such  as  eosin,  is  injected 
into  the  cutis  of  the  forearm  of  the  person  to  be  experimented  upon  in  such  a  manner  as 
to  produce  a  wheal,  it  will  be  noticed  in  the  beginning  that  the  wheal  alone  is  colored; 
in  a  few  minutes  the  extension  of  the  coloring  will  be  noted  in  a  variable  area  of  skin 
around  the  wheal,  depending  upon  the  concentration  of  the  color  solution  used.  The 
coloring  matter  has  been  diffused  and  has  caused  a  local  reaction  that  can  be  noted 
from  the  coloring  of  the  tissues.  On  the  other  arm  of  the  same  person  the  same  quan- 
tity of  the  color  solution  is  injected  in  the  form  of  a  wheal,  but  immediately  before  or 
shortly  after  the  injection  the  upper  arm  is  constricted  with  a  rubber  band.  It  will 
be  noted  that  the  visible  coloring  of  the  skin  area  in  the  ligated  arm  is  decidedly  larger 
than  in  the  one  which  has  not  been  ligated;  the  color  solution  has  extended  into  the 
surrounding  area  to  a  great  extent  and  in  large  quantities.  There  must  have  been 
a  hyperabsorption  of  the  color  solution  at  the  point  of  application,  and  there  must 
necessarily  have  been  less  absorbed  into  the  general  circulation. 

If  now  a  1  per  cent,  cocain  solution  is  injected  into  the  skin  of  the  forearm  in  like 
manner,  an  anesthetic  w^heal  will  remain  for  a  variable  length  of  time.  If  the  arm 
is  ligated  before  or  immediately  after  injection,  anesthesia  of  the  skin  will  be  dis- 
tributed in  a  considerable  area  beyond  the  wheal,  a  result  only  possible  in 
unligated  extremities  by  using  a  very  concentrated  solution  of  cocain.  From 
these  results  it  will  be  noted  that  the  anesthetic  action  of  cocain  has  been  increased. 
This  can  only  be  explained  by  assuming  that  hyperabsorption  has  taken  place  at 
the  point  of  injection.  The  anesthetized  tissues  remain  in  this  condition  as  long  as 
the  circulation  is  interrupted  and  even  some  little  time  after  the  removal  of  the  rubber 
band.  Only  after  the  return  of  the  circulation  do  reparative  changes  begin  which 
are  necessary  for  a  return  of  the  tissues  to  normal.  As  has  already  been  noted, 
it  is  probable  that  a  disintegration  of  the  cocain  has  taken  place.  Since  the 
work    of    Corning    (in    1885),    the     Esmarch    bandage    for    ligating    extremities 


FURTHER   AIDS   TO   LOCAL   AXESTIIESLA  131 

and  thereby  increasinji-  tlie  local  action  of  cocaln  has  come  into  general  use 
as  an  important  aid  to  local  anesthesia.  The  tight  bandaging  of  an  extremity, 
continued  for  a  long  time,  by  interfering  with  the  metabolism  of  the  part  and  by 
the  compression  of  nerve  trunks,  must  necessarily  aid  in  diminishing  sensation. 

AVith  the  increased  local  action  and  delay  of  absorption  of  cocain  on  account  of 
the  ligature,  a  lessening  of  toxicity  must  necessarily  occur. 

If  0.1  per  kilo  of  a  10  per  cent,  cocain  solution  is  injected  into  the  hind  legs  of  two 
rabbits  of  the  same  weight,  after  first  ligating  the  leg  of  one  of  the  rabbits  with  a 
rubber  band,  the  rabbit  with  the  unligated  leg,  as  a  rule,  dies  in  severe  convulsions  in 
a  few  minutes,  while  the  rabbit  with  the  ligated  leg  shows  no  evidence  of  poisoning. 
If  the  band  be  released  after  half  an  hour  mild  symptoms  of  poisoning  occur,  which, 
however,  do  not  cause  the  death  of  the  animal.  In  fact,  in  some  cases  the  animal 
remains  perfectly  normal.  This  typical  course,  which  was  known  to  Kummer  and 
Kohlhardt,  led  the  latter,  upon  the  advice  of  Czylhartz  and  Donath,  to  carry  out 
experiments  of  this  kind  in  animals  poisoned  wath  strychnin.  He  also  noted 
that  the  general  toxicity  following  the  injection  of  usually  fatal  doses  of  cocain 
was  diminished  or  entirely  prevented  by  the  ligation  of  the  leg  of  a  rabbit,  the 
intensity  depending  upon  the  length  of  time  the  leg  was  ligated.  If  the  ligature 
remained  in  place  for  an  hour  or  longer  all  symptoms  of  poisoning  were  avoided. 
These  observations  are  explained  by  the  fact  that,  absorption  being  prevented, 
disintegration  of  the  cocain  occurred  at  the  point  of  injection.  It  has  been  observed 
by  Kleine  that  absorption  following  the  tight  ligating  of  a  limb  is  not  entirely 
prevented  but  only  delayed. 

We  are  indebted  to  Klapp  for  his  valuable  investigations  regarding  parenchyma- 
tous absorption.  He  used  for  this  purpose  a  locally  indiflPerent  substance  such. as 
milk  sugar,  which,  following  its  injection,  rapidly  appeared  in  the  urine.  He  used  this 
observation  to  determine  the  rapidity  or  delay  of  absorption.  He  was  able  to 
repeatedly  demonstrate  that  active  hyperemia  increased  the  rapidity  of  absorption, 
whereas  a  slight  passive  hyperemia,  such  as  is  produced  by  the  application  of  a  rubber 
band  to  the  extremities,  or  following  simple  elevation,  caused  a  delay  in  the  excretion 
of  the  injected  milk  sugar.  Both  of  these  means,  either  simple  elevation  or  the  appli- 
cation of  a  rubber  bandage,  caused  a  marked  increase  in  activity  of  local  anesthetic 
substances  like  cocain  and  similar  drugs. 

THE    EFFECT    OF    INTENSE    CHILLING    OF    THE    TISSUES    ON   LOCAL 
AND    GENERAL    POISONING. 

Another  means  for  diminishing  the  local  vitality  of  the  tissues  and  delaying  absorp- 
tion is  brought  about  by  cooling  with  either  the  ether  or  ethyl  chloride  spray.     By 


132  LOCAL  ANESTHESIA 

this  means  it  is  possible  to  increase  the  local  activity  of  various  drugs,  which  can 
be  readily  observed  in  connection  with  local  anesthetic  substances.  In  a  previous 
chapter  intense  and  long-continued  anesthesia  was  described  following  the  application 
of  cocain  in  ethyl  chloride.  This  was  not  due  to  the  simple  combination  of  cocain 
anesthesia  with  the  anesthesia  from  cold,  but  to  the  increased  local  effect  of  cocain 
from  the  cooling  of  the  tissues.  This  same  effect  can  be  noticed  if  a  mucous  membrane 
is  frozen  after  a  watery  solution  of  cocain  hydrochlorate  is  applied.  The  tran- 
sitory anesthesia  from  cold  disappears  rapidly  to  be  followed,  however,  by  a  very 
intense  cocain  anesthesia  in  a  very  few  minutes.  If  it  is  desired  to  combine  cocain 
with  anesthesia  from  cold  in  a  practical  manner,  the  mucous  membrane  should  first 
be  chilled  and  then  cocainized,  or  the  cocain-ethyl  chloride  spray  can  be  used.  While 
waiting  for  the  action  of  cocain  to  begin,  a  second  chilling  of  the  surface  is  carried 
out  before  operation.  The  action  of  cold  can  also  be  tested  in  the  increasing  local 
anesthetic  effect  upon  the  wheal. 

Experiment  1. — Two  wheals  are  injected  with  0.5  per  cent,  cocain  solution  next 
to  one  another  on  the  arm  of  the  person  to  be  experimented  upon,  both  immediately 
becoming  anesthetic.  One  of  these  wheals  is  then  chilled  until  frozen,  the  second  is 
undisturbed.  In  the  latter  wheal  sensation  returns  in  about  eighteen  minutes,  and 
the  anesthesia  has  been  confined  to  the  wheal.  In  the  one  which  had  been  frozen 
the  duration  of  anesthesia  is  about  double  that  of  the  latter.  Five  minutes  after 
the  injection  the  anesthesia  from  cold  disappears,  the  skin  is  hyperemic,  and 
anesthesia  is  found  to  have  extended  for  some  distance  beyond  the  point  of  injec- 
tion, so  that  an  area  of  about  double  the  size  of  the  original  wheal  becomes  insensitive. 
After  about  ten  minutes  this  secondary  anesthesia  disappears.  Similar  symptoms 
occur  if  the  skin  is  frozen  just  before  injection. 

Experiment  2. — Two  wheals  not  widely  separated  from  one  another  on  the  arm  of 
the  person  to  be  experimented  upon  are  injected  with  0.5  c.c.  of  a  0.5  per  cent, 
cocain  solution.  The  area  about  one  of  the  wheals  is  frozen,  the  other  being  left 
undisturbed.  In  the  case  of  the  one  in  which  the  surrounding  area  has  been  frozen 
anesthesia  persists  for  twenty  minutes;  in  the  second  wheal  this  action  does  not 
occur. 

Both  of  these  experiments  readily  demonstrate  that  decided  increase  in  the  action 
of  cocain  is  produced  by  the  cooling  of  the  tissues.  Other  local  anesthetics  show 
similar  results.  This  method  of  increasing  cocain  activity  by  the  joint  use  of  ether 
or  ethyl  chloride  sprays  has  been  successful  for  some  time  in  practice,  as,  for 
instance,  in  the  extraction  of  teeth  (Wiener,  Schleich  and  others).  The  combination 
of  cocain  anesthesia  with  the  ethyl  chloride  spray  has  been  very  extensively  used  by 
Schleich  and  Hackenbruch.  It  is  important  to  remember  that  the  anesthetic  action 
of  cold  with  cocain  anesthesia  permits  the  use  of  dilute  solutions  of  cocain  in  tissues 


Fl'RTHER   AIDS    TO    LOCAL   ANESTHESIA  133 

where  an  intense  and  long-continued  anesthesia  is  necessary,  which  without  cold  could 
only  be  produced  by  using  much  stronger  solutions.  The  knowledge  gained  from 
these  facts  should  be  of  practical  value  in  the  development  of  the  art  of  local  anesthesia. 
If  cooling  of  the  tissues  diminishes  their  vitality,  thereby  delaying  absorption  and 
increasing  the  local  actiA'ity  of  various  drugs,  it  must  likewise  diminish  or  ])revent 
the  general  toxic  acti(Ui  of  these  sul)stances. 

The  fact  that  cooling  delays  parenchymatous  absorption,  whereas  an  increase  in 
temperatrue  increases  it,  was  long  known  and  in  almost  daily  use  by  physicians. 
It  has  again  been  demonstrated  in  a  very  interesting  manner  by  Klapp  in  his 
experiments  with  milk  sugar.  The  effect  of  the  chilling  of  the  tissues  on  absorp- 
tion and  the  general  action  of  poisons  was  demonstrated  by  Kossa  following  the 
rejiorts  of  Claude  Bernard  and  L.  Brunton. 

Kossa  injected  into  the  ears  of  rabbits,  which  had  been  cooled  to  a  temperature 
of  +5°  to  +7°,  potassium  cyanide,  strychnine,  and  picrotoxin  in  doses  which,  in  the 
control  animals,  produced  death,  or  very  severe  symptoms  of  poisoning.  With  con- 
tinued cooling  of  the  parts  the  injection  did  not  produce  the  slightest  symptom  of 
poisoning  and  even  after  the  cooling  had  been  stopped  for  one  and  a  half  hours  symp- 
toms did  not  occur.  These  same  results  can  be  readil}'  determined  with  solutions 
of  cocain. 

K.vpcriiucnt  3. — Rabbit,  weighing  1450  grams;  the  skin  of  the  back  having  l)een 
freed  from  hair  was  chilled  with  the  ether  spray,  following  which  0.15  (  =  0.05  per 
kilo)  cocain  in  10  per  cent,  solution,  was  injected  and  the  cooling  was  continued  at 
the  point  of  injection  by  means  of  an  ice-cap  filled  with  ice  and  salt.  Symptoms  of 
poisoning  did  not  occur.  After  one  hour  the  cooling  was  stopped.  Ten  minutes 
later  mild  symptoms  of  poisoning  occurred,  such  as  excitement  and  paresis  of  the 
extremities.  Convulsions  and  coma  did  not  occur.  The  animal  appeared  perfectly 
normal  in  about  fifteen  minutes.  A  control  animal  injected  in  the  same  manner 
with  0.05  cocain  per  kilo  but  without  chilling  exhibited  in  five  minutes  the  usual 
symptoms  of  acute  cocain  poisoning,  with  convulsions  and  coma.  Death,  however, 
did  not  occur. 

Experiment  4. — A  third  rabbit,  injected  with  0.1  per  kilo  cocain  in  30  per  cent, 
solution,  in  an  area  of  the  back  which  had  been  freed  from  hair  and  cooled  with  the 
ice  bag,  showed  severe  symptoms  of  poisoning  but  did  not  die.  These  symptoms 
occurred  about  seventeen  minutes  after  the  injection,  following  which  the  cooling  was 
stopped;  severe  convulsions  and  coma  now  occurred  but  the  animal  rapidly  returned 
to  normal.  The  injection  of  0.1  cocain  per  kilo  in  30  per  cent,  solution  injected 
subcutaneously  is,  without  these  additional  measures,  an  absolutely  fatal  dose. 

These  experiments  can  be  continued  to  further  advantage  in  the  following 
manner:  A  rabbit  is  placed  in  a  close-fitting  box,  a  small  hole  being  sawed  in  one  side 


134  LOCAL  ANESTHESIA 

and  the  unshaven  hind  leg  drawn  out  and  fixed  in  this  opening.  The  leg  is  surrounded 
with  wet  cotton  and  placed  in  a  vessel  containing  ice. 

Experiment  5. — Rabbit  weighing  1800  grams;  10:30  o'clock  freezing  of  the  hind  leg 
begun;  10:40  o'clock  injection  of  0.18  cocain  in  20  per  cent,  solution  subcutaneously 
in  the  middle  of  the  upper  leg,  above  the  bandage  holding  the  leg  in  place.  The  point 
of  injection  is  cooled  with  the  ether  spray  followed  by  covering  the  leg  with  wet 
cotton  and  ice.  No  symptoms  of  poisoning  occur;  11:40  o'clock  the  cooling  is 
stopped  and  the  animal  freed;  11:45  mild  symptoms  of  poisoning,  as  excitement 
and  paresis  of  the  extremities,  convulsions  and  coma  do  not  occur;  12:05  o'clock 
animal  is  apparently  normal. 

Control  experiment:  rabbit,  weighing  1900  grams;  the  animal  is  confined  in 
like  manner  and  0.19  cocain  in  20  per  cent,  solution  injected.  In  five  minutes 
severe  convulsions  occur,  death  following  six  minutes  after  the  injection. 

These  experiments  permit  us  to  see  that  general  toxic  symptoms  do  not  occur 
when  the  vitality  of  the  tissues  is  damaged  by  cooling,  owing  to  the  delayed 
absorption  of  the  cocain.  Furthermore,  the  symptoms  of  poisoning  are  very 
much  diminished  as  long  as  the  cooling  continues,  and  may  be  entirely  absent  if 
the  cooling  be  continued  for  some  time. 

The  cooling  of  the  tissues  upon  the  local  toxic  action  of  anesthetic  substances  is 
of  much  practical  interest,  but  it  must  always  be  kept  in  mind  that  even  with  its 
use  the  same  care  as  has  already  been  mentioned  must  be  observed. 


THE   EFFECT    OF    SUPRARENIN    (ADRENALIN)    ON   LOCAL   AND    GENERAL 
POISONING. 

From  an  entirely  unexpected  source  surgery,  and  particularly  local  anesthesia, 
has  been  offered  a  drug  the  local  application  of  which  causes  a  contraction  of 
the  bloodvessels,  rendering  the  tissues  bloodless  and  diminishing  their  vitality, 
thereby  causing  an  increase  of  the  local  action  of  drugs  and  a  diminution  of  their 
general  toxic  action. 

We  have  known  since  the  early  important  work  of  Brown-Sequard  that  the  removal 
of  both  suprarenal  glands  in  animals  caused  death,  or  when  this  did  not  occur,  it  was 
supposed  that  the  animal  possessed  an  accessory  suprarenal  gland.  The  fresh  or 
dried  suprarenal  glands  of  healthy  animals  contain  a  toxic  body  (Pellacani,  1879) 
having  a  peculiar  pharmacological  action  when  administered  to  animals  or  man, 
and  as  partly  described  by  Vulpian  in  1856,  possesses  definite  chemical  reactions. 
Solutions  of  this  gland  or  the  fresh  gland  itself  rapidl}^  become  red  or  brown  when 
exposed  to  the  air.    They  become  green  upon  the  addition  of  ferric  chloride,  again 


FURTHER  AIDS   TO  LOCAL  ANESTHESIA  135 

becoming  red  with  the  addition  of  alkalies  or  the  halogens,  these  reactions  being 
similar  to  those  for  guiacol. 

Attempts  were  made  by  many  experimenters  to  isolate  the  active  principle  of  the 
suprarenal  gland,  the  experiments  of  Fuerth  and  Abel  coming  nearer  the  solution 
of  this  problem  than  any  previous  workers.  They  each  prepared  an  extract  of  supra- 
renal which,  though  not  identical,  possessed  the  same  physiological  and  chemical 
characteristic  reactions.  Fuerth  called  his  preparation  suprarenin  and  Abel  called 
his  epinephrin.  In  the  year  1901,  Takamine  and  Aldridge,  independently  of  each 
other,  succeeded  in  separating  the  active  principle  of  this  gland  in  crystalline  form, 
the  product  being  known  as  adrenalin. 

Fuerth  was  able  to  demonstrate  that  his  suprarenin  was  identical  with  adrenalin. 
Suprarenin  was  first  placed  upon  the  market  in  pure  crystalline  form  by  Parke, 
Davis  &  Co.,  of  Detroit,  Mich.,  under  the  name  of  adrenalin.  It  is  now  prepared  by 
a  large  number  of  German  and  foreign  pharmaceutical  houses  both  in  crystalline 
form  and  in  the  form  of  a  1  to  1000  solution  and  marketed  under  the  various  trade 
names  of  adrenalin,  suprarenin,  eudrenal,  epirenan,  paranephrin,  tonogen,  etc.  The 
action  of  all  these  various  preparations  is  identical,  but  we  have  chosen  the  one 
known  as  suprarenin  for  our  work. 

Pure  basic  suprarenin  is  a  white  or  slightly  red  or  brown  crystalline  powder  pos- 
sessing the  properties  of  an  alkaloid.  It  is  soluble  with  difficulty  in  cold  water,  but 
readily  soluble  in  hot  water.  It  does  not  deteriorate  at  a  temperature  of  100°,  and 
combines  with  the  acids  to  form  salts.  In  attempting  to  dissolve  this  substance  in 
water  the  solutions  are  promptly  colored  red  or  brown  owing  to  oxidation  of  the  supra- 
renin by  the  oxygen  of  the  air.  Solutions  remain  clear  and  colorless  in  a  vacuum. 
By  the  addition  of  hydrochloric  acid  to  the  solvent,  solutions  remain  clear  and  unin- 
fluenced by  boiling  (Braun).  Suprarenin  is  extremely  sensitive  to  the  action  of 
alkalies.     Synthetic  suprarenin  has  been  prepared  by  the  Hoechster-Farbwerke. 

After  the  chemical  constitution  of  suprarenin  was  determined  by  Aldrich,  Pauly, 
Stolz,  and  Friedmann,  the  chemists  Stolz  and  Flaecher  of  the  Hoechster-Farbwerke 
were  able  to  produce  suprarenin-like  substances  from  guaiacol.  This  substance  pos- 
sessed the  same  contractile  power  on  the  bloodvessels  and  the  ability  to  raise  blood- 
pressure  as  the  organ  preparations  and  showed  the  same  pharmacological  properties 
only  in  a  lesser  degree.  The  first  pharmacological  investigations  of  this  product 
were  carried  out  by  Meyer,  Loewi  and  von  Biberfeld. 

The  hydrochloric  acid  methyl-amino-ethanol-guaiacol  compared  in  chemical  and 
physiological  reactions  very  closely  to  those  of  the  organic  suprarenin,  possessing, 
however,  only  about  half  the  physiological  activity  of  the  organ  preparation.  There 
was  another  physical  difference  observed  between  these  two  preparations:  the  organ 
preparation  rotating  polarized  light  to  the  left,  whereas  the  synthetic  preparation 


136  LOCAL  ANESTHESIA 

was  optically  inactive,  which  according  to  chemical  nomenclature  is  called  racem- 
form.  Flaecher  was  able  to  convert  the  optically  inactive  synthetic  suprarenin  into 
two  components,  one  being  optically  dextrorotary  (dextrogyre)  and  the  other  being 
levorotary  (levogyre).  The  latter  is  similar  to  the  organ  suprarenin.  These  two 
components  were  designated  D-suprarenin,  and  L-suprarenin.  The  latter  product, 
synthetic  L-suprarenin,  is  identical  in  its  pharmacological  reactions  with  organ  supra- 
renin, as  has  been  demonstrated  by  the  inxestigations  of  Cushing,  Abderhalden, 
Mueller,  Thies,  Slavu.  The  author  has  used  for  several  years  the  synthetic  prepara- 
tion made  by  the  Hoechster-Farbwerke  which  he  has  tested  as  to  its  power  of 
contracting  the  bloodvessels  and  whether  it  could  be  used  as  a  substitute  for  the 
organ  suprarenin.  It  was  found  suitable,  but  larger  doses  were  necessary  than  with 
the  use  of  organ  suprarenin.  This  preparation  was  not  stable  either  alone  or  in 
combination  with  novocain,  for  which  reason  within  a  short  time  the  organ  suprarenin 
we  again  used.  The  investigation  of  the  newer  products  was  taken  up  with  much 
misgiving,  first  using  D-suprarenin,  which  showed  so  little  contractile  power  on  the 
bloodvessels  that  it  was  not  suitable  for  operations;  the  L-suprarenin,  however, 
which  is  marketed  under  the  name  of  synthetic  suprarenin,  we  have  used  for  some 
time  in  the  same  form  and  the  same  dosage  as  the  organ  suprarenin  and  have  been 
unable  to  determine  any  difference  in  its  action  from  the  latter  preparation. 

Double  inguinal  hernia  operations  have  been  used  as  a  test  for  these  drugs,  one 
side  being  anesthetized  with  the  usual  novocain  solution  with  the  addition  of  organ 
suprarenin,  the  other  side  being  anesthetized  with  a  similar  quantity  of  novocain  to 
which  was  added  the  preparation  to  be  tested.  The  operator  was,  therefore,  in  a  posi- 
tion to  pro\'e  the  identity  of  action  of  L-suprarenin  with  organ  suprarenin.  These 
iii\  tstigations,  which  were  carried  on  for  many  years  by  German  chemists,  were  of 
immense  importance  in  a  practical  way,  inasmuch  as  the  cleanliness  and  constancy 
of  action  of  a  synthetic  preparation  is  more  certain  than  a  preparation  made  from 
organs  removed  after  slaughter. 

The  most  noticeable  effect  following  the  use  of  the  juice  of  the  suprarenal  gland 
or  its  extracts  is  a  transitory  rise  of  blood-pressure,  infinitesimal  doses  being  sufficient 
to  bring  this  about  (according  to  Moore  and  Purinton  0.000000245  to  0.000024  of  the 
extract  per  kilo  for  dogs).  The  cause  of  this  rise  of  blood-pressure  is  due  to  the  direct 
stimulation  of  the  heart  (Gottlieb,  Hedboom,  Schaefer)  and  to  the  contraction  of  the 
arteries  and  capillaries  of  the  body.  The  smooth  muscle  fibers  of  other  organs  are 
influenced  in  like  manner.  According  to  Jacoby,  Boruttau,  and  Pal  the  peristalsis  of 
the  bowel  following  the  intravenous  administration  of  suprarenal  extract  is  stopped. 
Lewandowski  has  shown  that  the  intravenous  or  subcutaneous  injection  of  suprarenal 
extract  causes  the  contraction  of  the  smooth  muscle  fibers  of  the  skin,  so  that  in  the 
hedgehog  the  bristles  rise  up.    The  hair  can  also  be  seen  to  bristle  following  the  use 


Frirnih'h'  aids  to  local  axljstiU'Jsia  i;!7 

of  this  substance  in  cats.  Schactcr  has  stated  that  extracts  of  sui)rarenal  cause  a 
contraction  of  the  niuscuhiture  of  the  uterus.  In  hirj;e  doses  this  substance  is  a 
severe  poison  and  causes  the  death  of  the  animal  experimented  upon  in  a  short  time 
with  paralytic  symptoms  and  pronounced  fall  in  blood-pressure,  the  latter  being 
preceded  by  a  rise  in  blood-pressure. 

Cybulski  caused  death  in  rabbits  after  the  intravenous  injection  of  1  c.c.  of  a  10 
per  cent,  solution  of  the  extract,  but  this  dose  could  l)e  borne  without  causing  any 
disturbance  if  it  was  diluted  ten  to  twenty  times.  The  active  substance  can  be 
found  in  the  urine  fifteen  minutes  after  a  subcutaneous  injection  (Cybulski,  Bardier, 
and  Frenkel),  and  following  the  administration  of  fatal  doses  Blum  and  Zuelzer 
found  glycosuria  constantly  present. 

The  question  whether  the  action  of  this  substance  on  the  smooth  muscle  fibers, 
particularly  those  of  the  bloodvessels,  was  of  central  or  peripheral  origin  has  been 
decided  in  favor  of  the  latter.  Biedl  observed  in  excised  organs,  such  as  the  kidney 
and  extremities,  through  which  physiological  solutions  containing  suprarenal  extract 
were  passed,  a  contraction  of  the  bloodvessels  to  such  an  extent  that  the  flow  from  the 
\eins  ceased  entirely.  Hedboom  and  Schaefer  observed  the  direct  action  of  this 
substance  upon  the  heart  excised  from  a  mammal;  the  organ  began  to  pulsate  after 
the  application  of  suprarenal  extracts.  Bates,  Dor,  Darier,  and  Koenigstein  noted 
the  contraction  of  the  bloodvessels  of  the  conjunctiva  following  the  instillation  of 
the  extract  into  the  eye.  This  same  observation  was  made  in  connection  with 
other  mucous  membranes,  and  Velich  observed  the  anemia-producing  power  fol- 
lowing local  application  of  suprarenal  extracts  to  granulating  wounds — eczema  and 
burns — in  both  animals  and  man.  From  these  results  we  must  believe  that  the 
contraction  of  bloodvessels  is  of  peripheral  origin. 

It  is  of  interest  to  note  that  the  bloodvessels  of  various  organs  react  more  or  less 
intensely  to  the  action  of  suprarenin.  The  action  is  very  marked  in  the  skin,  less 
intense  in  the  stomach,  intestines,  and  bladder,  and  not  at  all  upon  the  vessels  of  the 
lungs  (Langley,  Brodie,  and  Dixon).  Its  action  on  the  coronary  vessels  does  not  cause 
contraction  but  rather  dilatation  (Langendorff ) .  Laewen  has  proved  that  suprarenin 
is  destroyed  by  the  living  bloodvessel  walls  so  that  poisoning  of  the  body  from  this 
substance  is  overcome  by  this  action. 

The  anemia-producing  properties  of  suprarenal  extracts  ha^•e  proved  of  much  value 
in  laryngological  and  rhinological  operations  for  the  purpose  of  allaying  hemorrhage 
(Swain,  ]\Ioure,  Brindel,  Harmer,  Rode,  Rosenberg).  Following  the  application  of 
1  to  lOOO  to  1  to  5000  solutions  of  suprarenin  to  the  mucous  membrane  of  the  nose 
or  larynx  turgescence  is  diminished  at  once,  so  that  the  cavities  and  accessory  cavi- 
ties become  more  accessible.  The  mucous  meml)rane  becomes  gray  and  completely 
bloodless  so  that  no  bleeding  occurs  after  cutting. 


138  LOCAL  ANESTHESIA 

Lermoyez  called  this  substance  "Alkaloid  der  Esmarchschen  Blutleere."  These 
remarkable  observations  following  the  subcutaneous  injections  of  suprarenal  solutions 
have  been  further  tested  in  healthy  persons  by  experts  and  the  effects  have 
been  studied  in  its  almost  daily  use  in  operations.  It  was  shown  that  tissues  freely 
infiltrated  according  to  Schleich's  method  with  a  1  to  1,000,000  suprarenal  solution 
became  bloodless  in  a  few  minutes.  There  was  also  noticed  an  absence  of  parenchyma- 
tous bleeding  on  cutting  these  tissues,  whereas  the  arterial  and  venous  bleeding  was 
markedly  diminished.  Following  the  injection  of  stronger  suprarenal  solutions  arteries 
of  larger  caliber,  as,  for  instance,  the  arteries  of  the  finger,  were  closed  completely 
by  the  contraction  of  their  lumen.  We  are  in  position  to  cause  a  circumscribed 
anemia  of  the  tissues  of  long  duration  by  means  of  suprarenin  which  is  not  far  behind 
that  occasioned  by  the  constriction  of  an  Esmarch  bandage.  This  action  of  supra- 
renin is  one  which  has  long  been  sought  in  surgery.  It  is  now  possible  to  carry  out  all 
operations,  wherever  necessary,  without  the  loss  of  blood.  This  was  formerly  only 
possible  on  the  extremities.  The  anemia  can  be  produced  with  extremely  small 
doses  of  suprarenin;  5  drops  are  sufficient  of  a  0.1  per  cent,  suprarenal  solution  to 
100  c.c.  of  salt  solution  which  contains  this  substance  in  a  dilution  of  about  1  to 
600,000.  A  fraction  of  a  milligram  of  suprarenin  is  sufficient  to  make  a  large 
operative  field  bloodless,  provided  this  agent  is  freely  injected  in  very  dilute  solu- 
tion and  evenly  divided  in  the  tissues.  It  is  not  necessary  to  saturate  the  operative 
field  with  suprarenin  solutions.  The  field  will  become  much  more  bloodless  if  the 
area  around  the  operative  field  is  injected  with  suprarenin  solution,  thus  cutting 
off  its  blood-supply,  as  it  were.  The  technique  of  the  injection  is  similar  to  that 
which  will  be  described  later  for  anesthetizing  operative  fields.  B.  Mueller  recently 
described  the  value  of  suprarenin  anemia  in  operations  upon  the  parenchymatous 
organs  such  as  the  liver  and  kidney.  His  observations  upon  the  human  liver  have 
been  proved  incorrect.  This  organ  has  been  infiltrated  repeatedly  with  suprarenal 
solutions  in  cholecystectomies  and  injuries  to  the  liver  without  showing  any 
difference  in  the  bleeding.  This  is  only  what  should  be  expected  from  the  rigid 
non-contracting  liver  veins. 

The  blood-checking  property  of  the  juice  of  the  suprarenal  gland  has  long  been 
known  to  those  employed  in  slaughter-houses.  It  has  been  stated  that  in  the 
slaughter-houses  at  Leipsic  the  butchers  would  frequently  apply  the  juice  squeezed 
from  the  suprarenal  gland  to  wounds  for  the  purpose  of  stopping  hemorrhage. 

Suprarenin  is  of  importance  in  local  anesthesia  owing  to  its  anemia-producing 
properties.  Suprarenin  is  not  an  anesthetic,  but  local  action  of  other  drugs  is 
made  much  more  intense  if  combined  with  it.  It  has  been  frequently  observed  by 
ophthalmologists  (Dor,  Darier,  Koenigstein,  Lichtwitz,  Landolt,  and  others)  that 
cocain,  holocain,  atropin,  eserin,  and  other  drugs  act  much  more  intensely  upon 


FURTHER   AIDS    TO   LOCAL   AXKSTIIKSLi  139 

the  conjunctiva  of  the  eye  if  combined  with  suprarenal  extract  or  if  the  latter  had 
been  previously  instilled  into  the  eye.  Rhinologists  and  laryngologists  (Swain, 
Bukofzer,  Rode,  and  others)  observed  the  same  results,  particularly  following  the  use 
of  cocain.  The  value  of  suprarenal  extracts  in  local  anesthesia  for  the  extraction 
of  teeth  was  observed  by  Carpenter,  Peters,  IVIinter,  Battier,  Nevreze,  and  Moeller. 
As  a  result  of  the  exhaustive  studies  made  with  suprarenin  this  substance  has  been 
l^roved  a  very  valuable  aid  to  anesthesia. 

It  was  observed  that  the  local  anesthetic  power  of  cocain  solutions  was  enormously 
increased  by  the  addition  of  very  small  quantities  of  suprarenin.  Dilute  cocain 
solutions  with  the  added  suprarenin  acted  much  more  intensely  than  concentrated 
solutions  without  this  addition,  and  anesthesia  was  observed  in  tissues  far  beyond 
the  point  infiltrated.  The  conductivity  of  nerves  was  readily  interrupted,  this  being 
observed  even  in  those  mixed  nerves  which  were  usually  very  resistant  to  the  action 
of  cocain.  At  the  same  time  the  duration  of  cocaine  anesthesia  was  prolonged  for 
hours.  The  extent  of  the  anemia  of  the  tissues  and  anesthesia  are  independent  of 
one  another.  The  first  depends  upon  the  suprarenin  content  while  the  latter 
depends  upon  the  quantity  of  cocain  in  the  solution. 

Further  experiments  were  undertaken  to  determine  the  effect  of  suprarenin  upon 
iS-eucain  and  tropacocain.  It  was  observed  that  both  eucain  and  tropacocain 
interfered  with  the  action  of  the  suprarenin  in  contracting  bloodvessels.  This  w^as 
noticeable  with  tropacocain,  as  already  mentioned  by  Rode.  The  addition  of 
suprarenin  to  solutions  of  eucain  does  not  cause  an  increase  in  the  intensity  of  its 
action  to  the  same  extent  as  is  noted  with  solutions  of  cocain.  The  addition  of 
suprarenin  to  tropacocain  solution  is  of  very  little  value.  The  effect  of  these  three 
agents  upon  the  action  of  suprarenin  is  well  shown  in  the  curves  drawn  by  Laew^en. 

Laewen,  by  means  of  a  canula  fastened  in  the  aorta,  flushed  the  vessels  of  the  hind 
leg  of  an  animal  under  constant  pressure,  the  fluid  dropping  out  of  the  vena  cava. 
The  rapidity  of  flow  from  the  vessels  under  constant  pressure  was  determined  by 
counting  the  number  of  drops  per  minute. 

Fig.  6  shows  the  results  of  these  experiments.  The  abscissa  gives  the  time  in  minutes, 
the  ordinate  the  rapidity  of  flow  (drops  per  minute).  For  the  sake  of  clearness  the 
normal  number  of  drops  is  reduced  to  100  per  minute.  The  arrows  indicate  the 
time  of  beginning  the  flushing  with  the  different  experimental  solutions. 

Curve  A.  0.002  mg.  of  suprarenin  is  added  to  10  c.c.  of  indifferent  solution 
(Ringer's  solution  with  the  addition  of  1  per  cent.  gum).  The  number  of  drops 
sank  rapidly  from  100  to  11,  which  again  reached  the  normal  after  flushing  with 
Ringer's  solution.  An  interesting  observation  w^as  made  when  using  pure  cocain 
solutions  for  flushing,  a  fact  which,  however,  had  already  been  determined  by 
Kobert,  Brodie,  and  Dixon  and  this  was  that  cocain  solutions  alone  do  not  cause 
contraction  of  the  bloodvessels  when  passing  through  them. 


140 


LOCAL  ANESTHESIA 


Curve  B.  Solution  of  0.002  mg.  siiprarenin  and  0.01  gram  cocain  in  10  c.c.  of 
Ringer's  solution.  The  rapidity  of  flow  fell  promptly  from  100  to  3  drops,  which 
rapidly  approached  the  normal  after  flushing  with  indifferent  solution. 

Curve  C.  Solution  of  0.002  mg.  suprarenin  and  0.01  gram  of  /3-eucain  in  10  c.c. 
of  Ringer's  solution.    The  rapidity  of  flow  fell  from  100  to  63  drops  per  minute. 


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1 

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1 

\ 

/ 

^ 

■^ 

I 
1 

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,/ 

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/ 

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1 

/ 

y 

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k 

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Fig.  6. — The  influence  of  local  anesthetics  upon  suprarenin  in  reference  to  its  contractile  power 
upon  the  bloodvessels  (Laewen).  ^4,  suprarenin;  5,  suprarenin  with  cocain;  C,  suprarenin  with  eucain; 
D,  suprarenin  with  tropacocain. 

Curve  T).  Solution  of  0.002  mg.  suprarenin  and  0.01  gram  tropacocain  in  10 
c.c.  of  Ringer's  solution.  The  rapidity  of  flow  dropped  from  100  to  70  drops  per 
minute. 

It  can  readily  be  seen  from  these  experiments  that  cocain  was  the  only  one  of 
the  agents  experimented  with  which  did  not  interfere  with  the  contractile  power  of 
suprarenin.  The  other  anesthetics,  such  as  holocain,  akoin,  nirvanin,  and  subcutin, 
in  combination  with  suprarenin,  were  investigated  by  Recke.  The  anesthetic 
power  of  all  these  substances  was  increased  by  the  addition  of  suprarenin,  but  not 
to  the  same  extent  as  when  the  latter  substance  was  added  to  a  solution  of  cocain. 
Stovain  anesthesia  is  only  slightly  increased  by  the  addition  of  suprarenin.  The 
newer  substances,  alypin  and  novocain,  give  brilliant  results  when  combined  with 


J 


firthkr  aids  to  local  a.xesthlsia  141 

.sii[)rarciiiii.  This  can  he  reachly  seen  hy  (■()ni])arini'-  the  t'oHowin^  ex])erinients  with 
those  in  the  preceding  chapter  (k'xoted  to  these  drugs. 

Experiment  1. — Five  drops  of  a  1  to  lOOOsuprarenin  sohition  were  a(kled  to  100  c.c. 
of  a  0.1  per  cent,  sohition  of  alypin.  A  wheal  injected  into  the  skin  was  painfuL 
Skin  did  not  become  hyperemic.  The  white  wheal  was  in  the  centre  of  a  white  area 
several  times  the  diameter  of  the  original  wheal.  Anesthesia  of  the  wheal  lasted 
about  two  hours, when  sensation  gradually  returned.  Hyperemic  infiltrates  remained 
at  the  point  of  injection  until  the  next  day. 

Kxpeririimi  2. — One  drop  of  a  1  to  1000  suprarenin  solution  was  added  to  1  c.c.  of 
()..■)  per  cent,  alypin  in  0.8  per  cent,  salt  solution  and  injected  circularly  in  the  subcu- 
taneous tissues  of  the  fourth  finger.  The  injection  was  painful.  After  about  ten 
niimites  the  entire  finger  as  far  as  the  tip  became  completely  anesthetic.  In  about 
two  hours  sensation  began  to  return  and  reached  the  normal  in  about  three  hours. 
The  base  of  the  finger  remained  infiltrated  for  several  days,  being  red  and  painful. 
0.5  per  cent,  solutions  of  cocain  or  eucain  with  like  addition  of  suprarenin  did  not 
show  these  latter  effects. 

Experiment  3. — Five  drops  of  a  1  to  1000  suprarenin  solution  were  added  to  100 
c.c.  of  a  0.1  per  cent,  isotonic  novocain  solution.  A  wheal  was  formed  on  the  fore- 
arm; the  injection  was  painless;  anemia  very  pronounced.  Anesthesia  lasted  more 
than  an  hour,  disappearing  without  leaving  any  effect. 

Experiment  4. — Two  drops  of  a  1  to  1000  suprarenin  solution  were  added  to  1  c.c. 
of  a  1  per  cent,  novocain  solution.  A  wheal  formed  on  the  forearm.  Injection  pain- 
less. Anesthesia  around  the  wheal  lasted  about  four  hours.  Action  of  the  suprarenin 
very  pronounced.  After  the  disappearance  of  the  suprarenin  anemia  some  slight 
pain  was  felt  at  the  point  of  injection,  but  no  other  reaction. 

Experiment  5. — 0.5  c.c.  of  the  same  novocain  suprarenin  solution  was  injected 
subcutaneously  into  the  forearm.  The  skin  over  the  point  of  injection  as  well  as  the 
])arts  supplied  by  the  nerve  trunks  affected  by  the  injection  were  insensitive  for  tw^o 
and  a  half  to  three  hours.  The  action  of  the  suprarenin  was  very  pronounced  but 
disapi)eared  without  leaving  any  reaction. 

Experiment  6. — One  drop  of  a  1  to  1000  suprarenin  solution  was  added  to  each  cubic 
centimeter  of  a  0.5  per  cent,  novocain  solution.  The  base  of  the  fourth  finger  was  cir- 
cularly injected  with  1  c.c.  of  this  solution.  In  ten  minutes  the  entire  finger  was 
both  anemic  and  insensitive.  After  al)out  ten  minutes  a  return  of  sensation  was 
noted  in  the  tip  of  the  finger.  It  required  about  one  hour  for  complete  return  of 
sensation.     There  was  no  secondary  pain  or  swelling  of  the  finger. 

From  these  experiments  it  becomes  very  e^'ident  that  the  anesthetic  properties 
of  both  of  these  substances  are  enormously  increased  by  the  addition  of  supra- 
renin.    This  is  of  immense  importance  in  the  use  of  novocain,  as  the  anesthetic 


142 


LOCAL  ANESTHESIA 


power  of  this  substance  without  the  addition  of  suprarenin  is  too  fleeting  to  be 
of  practical  value.  There  is  no  doubt  that  the  influence  of  suprarenin  in  increasing 
the  local  anesthetic  power  of  this  substance  is  similar  to  that  produced  by  ligating 
the  extremities  or  cooling  the  tissues.  These  changes  again  are  brought  about  by  a 
diminution  of  the  vitality  of  the  tissues  from  the  suprarenin  anemia  associated  with 
delay  in  absorption  of  the  drug. 


6rcmm:0,20 

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/  2 

1  of  sugar  in  the  urine  • 


^           J  6  7  a.  Hours 

•  "without,    with  suprarenin.     (Klapp.) 


Klapp  has  graphically  shown  in  the  accompanying  diagram  the  action  of  supra- 
renin even  in  very  small  doses  upon  the  absorption  from  the  tissues.  He  injected 
beneath  the  skin  of  the  back  of  a  dog  10  c.c.  of  a  6.5  per  cent,  solution  of  milk  sugar, 
examining  the  urine  hourly  for  evidences  of  sugar.  Three  days  later  the  same  quantity 
of  this  solution  was  injected  with  the  addition  of  two  drops  of  a  1  to  1000  adrenalin 
solution.  The  urine  w^as  examined  in  the  same  manner.  In  Fig.  7  the  hours  are 
indicated  upon  the  horizontal  line,  whereas  the  vertical  line  indicates  the  quantity 
of  sugar  excreted  in  grams.  The  solid  line  shows  the  excretion  before  the  addition 
of  adrenalin.  It  will  be  noticed  that  the  excretion  of  sugar  begins  immediately, 
reaching  its  maximum  in  about  one  hour,  then  falls  slowly,  stopping  completely  in 
about  six  hours.  The  entire  quantity  of  sugar  obtained  in  the  urine  was  about  0.569 
gram.  The  dotted  line  shows  the  result  of  the  second  experiment,  where  absorption 
was  delayed  by  the  addition  of  adrenalin.  In  the  first  hour  no  sugar  was  found  in 
the  urine,  the  excretion  beginning  only  after  two  hours,  reaching  its  maximum  at 
the  end  of  five  hours,  which  was  considerably  less  than  in  the  first  experiment.  As 
long  as  eight  hours  after  the  injection  sugar  was  found  in  the  urine,  the  total  quantity 
obtained  being  0.343  gram. 

From  these  experiments  it  can  be  readily  seen  that  the  local  action  of  a  substance 


i 


FURTHER  AIDS   TO  LOCAL  ANESTHESIA  143 

is  iiuToasod  l)y  the  use  of  adrenalin.  Owing  to  delayed  pareneliyniatous  absorp- 
tion it  was  supposed  that  the  simultaneous  use  of  suprarenin  and  eocain  would 
naturally  diminish  the  toxic  action  of  the  latter  drug.  This  is  no  doubt  true,  but  the 
circumstances  are  of  course  different  from  those  in  the  physical  experiment.  The  use 
of  eocain  introduces  two  toxic  substances  into  the  body,  and  it  can  possibly  happen 
that  when  both  are  absorbed  the  toxicity  may  be  increased.  This  is,  however,  not 
the  case.  ^Nloure  and  Brindel  have  observed  in  rhinolaryngological  practice  that 
the  toxicity  of  eocain  is  markedly  diminished  by  the  use  of  suprarenin.  It  has 
also  been  demonstrated  in  suitable  animal  experiments  that  if  the  subcutaneous 
connective  tissue  be  first  injected  with  suprarenin  and  a  definite  time  allowed 
to  elapse  for  the  maximum  effect  to  take  place,  the  toxic  effect  of  eocain  solutions 
injected  into  the  anemic  tissues  was  not  only  delayed  but  also  diminished.  These 
observations  became  more  apparent  in  the  experiments  conducted  by  Doenitz,  in 
which  he  compared  the  action  of  pure  eocain  sohitions  injected  into  the  spinal  canal 
of  cats  with  that  of  eocain  and  suprarenin.  On  the  contrary,  Thiess  has  found  that 
eocain  and  suprarenin  when  injected  beneath  the  dura  w^ere  more  toxic  than  eocain 
alone. 

The  site  for  this  last  experiment  is  unfortunately  chosen,  as  the  spinal  canal  is 
not  a  suitable  place  for  determining  this  question,  inasmuch  as  the  action  of 
poisons  in  the  canal  is  not  only  due  to  their  absorption  but  also  their  direct 
action  upon  the  central  nervous  system.  Recently  Sikemeyer  in  his  experiments 
found  that  the  central  toxic  action  of  eocain  was  delayed  but  not  diminished  by 
suprarenin. 

The  fact  that  suprarenin  delays  the  absorption  of  eocain  solution  which  has 
been  injected  is  indisputable.  Likewise  the  fact  that  eocain  introduced  slowly 
into  the  circulation  is  less  toxic  than  when  rapidly  absorbed.  This  shows  that 
suprarenin  has  a  direct  effect  upon  the  toxic  action  of  eocain  under  suitable 
experimental  conditions.  The  practical  value  of  the  addition  of  suprarenin  to  eocain 
solutions  does  not  lie  in  the  fact  that  larger  doses  of  eocain  can  be  used,  but  that 
dilute  solutions  of  the  anesthetic  substance  can  produce  a  more  intense  reaction 
of  longer  duration  with  the  addition  than  without. 

The  value  of  suprarenin  solution  in  local  anesthesia  is  dependent  alone  upon  its 
vasoconstrictor  properties  with  the  consequent  anemia  of  the  tissues.  The  remark- 
able increase  of  the  local  anesthetic  power  of  a  substance  combined  with  suprarenin 
is  similar  in  its  action  to  the  ligation  of  extremities.  Esch  has  found  that  in  animals 
in  which  the  circulation  has  been  interrupted  the  action  of  suprarenin  causes  a  marked 
increase  in  the  local  action  of  eocain,  alypin,  and  novocain,  and  he  compares  these 
results,  which  are  in  nowise  dependent  upon  the  anesthetic  property  of  suprarenin, 
with  the  mordant  used  in  dyeing. 


144  LOCAL  ANESTHESIA 

x\nimal  experimentation  has  demonstrated,  just  as  we  have  observed  before  with 
cocain,  that  the  toxic  action  of  suprarenin  when  introduced  intravenously  into  the 
unobstructed  circulation  is  enormously  increased  over  that  introduced  subcutaneously, 
as  in  the  latter  method  absorption  is  hindered  and  a  portion  of  the  substance  is  not 
absorbed  at  all.  According  to  Batelli,  Taramasio,  Bouchard,  and  Claude,  0.0001  to 
0.0002  per  kilo  of  suprarenin  when  introduced  intravenously  into  rabbits  or  guinea- 
pigs  causes  death;  whereas  the  fatal  dose  for  subcutaneous  injection  is  more  variable, 
being  between  0.002  and  0.02  per  kilo,  the  fatal  dose  for  guinea-pigs  being  0.01  and 
for  rabbits  0.02  per  kilo.  Batelli  states  that  the  intravenous  injection  of  suprarenin 
is  about  forty  times  more  toxic  than  that  introduced  subcutaneously.  The  reason  for 
the  lessened  toxicity  of  this  substance  in  subcutaneous  injection  is  readily  understood, 
if  the  delay  of  absorption  due  to  the  local  action  of  this  substance  is  taken  into 
account. 

Toxic  symptoms  following  the  injection  of  suprarenin  in  animals  are  evidenced 
by  paralysis  of  the  extremities  with  tonic  and  clonic  convulsions,  opisthotonus  and 
mydriasis,  frequent  respiration,  edema  of  the  lungs,  anemia  of  the  viscera,  and  gly- 
cosuria. By  means  of  repeated  intravenous  injections  of  small  doses  of  suprarenin 
Josue,  Loeper,  Erb,  and  Kuelbs  were  able  to  produce  in  animals  calcification  of  the 
aorta,  coronary  vessels  and  the  heart. 

The  first  experiments  for  the  determination  of  the  dosage  to  be  injected  subcu- 
taneously were  made  by  the  author  in  1902.  He  injected  under  the  skin  of  the  fore- 
arm 1  to  1000  solution  of  suprarenin  in  increasing  doses.  After  the  injection  of  0.5 
mg.  (=  0.5  c.c.)  general  symptoms  occurred.  Five  minutes  after  the  injection  he 
experienced  a  sense  of  oppression  in  the  chest.  It  became  necessary  to  breathe 
more  rapidly  and  deeply.  Palpitation  followed,  the  pulse  increasing  from  64  to  94 
per  minute.  At  this  point  it  was  necessary  to  lie  down.  The  symptoms  dis- 
appeared completely  in  one  and  a  half  minutes;  glycosuria  did  not  occur.  When  the 
solution  of  adrenalin  was  diluted  ten  times  with  salt  solution,  1  mg.  could  be  injected 
without  noting  any  symptoms.  Doenitz  made  similar  observations  upon  himself, 
being  able  to  inject  1.5  mg.  of  adrenalin  in  1  to  1000  solution.  Thiess  injected  into 
two  persons  with  healthy  circulatory  systems  1  mg.  of  adrenalin  in  a  1  to  2000  solu- 
tion, in  another  case  0.2  mg.  in  a  1  to  10,000  solution  and  noted  that  the  blood-pres- 
sure was  increased  15  to  45  mm.  of  mercury.  This  occurred  a  few  minutes  after  the 
injection  and  lasted  three  to  eight  minutes.  No  other  general  symptoms  were  observed. 
The  experiences  of  recent  years  have  proved  that  the  dose  of  suprarenin  when  used 
for  local  anesthesia  is  of  apparently  no  consequence.  Inasmuch  as  the  dose  is  so 
small  and  is  injected  in  such  dilute  solution  (1  to  100,000  to  1  to  200,000),  general 
symptoms  from  this  substance  could  not  be  expected.  Physicians  use  suprarenin 
in  combating  symptoms  of  collapse  in  infectious  diseases.    The  quantity  used  subcu- 


Flh'TUl'Jh'   AIDS    TO   LOCAL   ANESTHESIA  145 

taiu'ously  is  as  follows:  Liehernu'istcr  and  Kaiier  give  1  to  (>  ing.  daily;  Kraus  G  mg. 
daily,  in  di\id(>(l  dosrs  of  ()..")  to  1  nig.  Eckert  gives  2  to  3  nig.  e\ery  three  or  four 
hours.  Kirchheini  from  his  experiments  claims  that  suprarenin  is  a  perfectly  harm- 
less drug  if  gi\en  1  nig.  hourly  or  every  four  hours.  In  severe  collapse  2  or  3  mg. 
at  one  dose;  24  mg.  have  been  given  in  twenty-four  hours — (K)  to  400  mg.  of 
sui)rarenin  in  a  1  to  1000  solution  being  given  in  all.  The  quantity  used  in  dilute 
solutions  for  local  anesthesia  must  necessarily  be  harmless,  and  only  clean,  active 
preparations  of  the  fresh  solution  should  be  used. 

An  unknown  writer  re])orte(l  in  the  "Zentralblatt  fiir  Gynakologie"  under  the 
title  "Warnung  vor  Adrenalin,"  that  in  1908  he  experienced  two  sudden  deaths 
from  syncope  in  women  just  before  the  beginning  of  chloroform  anesthesia.  The 
injection  of  0.0003  adrenalin  in  a  1  to  10,000  solution  into  the  portio  vaginalis  was 
for  the  purpose  of  preventing  hemorrhage.  These  cases  were  critically  investigated 
by  Fisch,  Neu,  Freund,  and  the  author.  They  were  declared  to  be  typical  chloro- 
form deaths. 

The  concentration  of  suprarenin  in  anesthetic  solutions  is  of  much  importance, 
as  the  intensity  of  the  local  action  of  suprarenin  and  the  duration  of  the  anemia 
of  the  tissues  is  dependent  upon  its  concentration.  Suprarenin  is  not  a  positive  hemo- 
static. For  this  reason  the  concentration  of  suprarenin  solutions  should  never  be 
sufficient  to  cause  a  complete  cessation  of  bleeding,  such  as  occurs  with  the  use  of 
the  Esmarch  bandage.  The  medium-sized  arteries  must  be  permitted  to  bleed  so 
that  they  can  be  ligated,  and  hemostasis  even  of  the  smallest  bleeding-point  must 
be  secured  by  ligature,  tampon,  or  a  compression  bandage,  so  that  all  possibility  of 
secondary  hemorrhage  can  be  avoided.  The  care  of  w^ounds  following  this  injection 
must  be  similar  to  that  following  use  of  the  Esmarch  band.  If  the  action  of  suprarenin 
be  too  intense  or  long  continued,  gangrene  of  the  tissues  can  occur,  particularly  if 
the  nutrition  of  the  part  is  already  interfered  with,  as,  for  instance,  in  arteriosclerosis 
of  the  extremities,  w^ounds,  or  plastic  flaps.  Siebert  has  collected  cases  of  this  kind. 
It  should  be  the  rule  not  to  inject  into  tissues  in  which  the  vitality  is  already 
reduced,  inasmuch  as  they  recover  very  slowly,  if  at  all,  from  the  effect  of  this 
agent.  In  plastic  flaps  it  is  important  to  remember  that  no  anesthetic  should  be 
injected  into  the  flap  or  near  the  vessels  supplying  its  pedicle. 

With  the  observance  of  these  rules  and  those  to  be  mentioned  in  the  later  chapters 
of  this  book  in  reference  to  the  special  directions  regarding  the  dosage  and  use  of 
novocain-suprarenin  solutions,  no  serious  consequences  need  be  feared.  The  limits 
of  usefulness  of  local  anesthesia  have  been  materially  increased  since  the  intro- 
duction of  suprarenin.  Its  results  are  more  certain,  the  technique  in  many 
instances  has  been  simi)lified,  and  danger  from  certain  operations  has  l)een  markedly 
reduced. 
10 


CHAPTER   IX. 

THE  VARIOUS  :\IETHODS  OF  USING  LOCAL  ANESTHETIC 
DRUGS. 

ANESTHESIA    OF    SUPERFICIAL    SURFACES,   AS    MUCOUS,   SEROUS    AND 
SYNOVIAL    MEMBRANES,    AND    WOUNDS. 

The  first  practical  use  of  cocain  anesthesia  as  made  by  Koller  consisted  in  the 
instillation  of  cocain  solutions  into  the  eye  for  the  purpose  of  making  the  con- 
]*uncti\a  insensitive.  Success  in  this  instance  led  to  the  immediate  application  of 
cocain  solutions  for  similar  purposes  to  other  mucous  membranes.  The  mucosa 
of  the  bladder  which,  as  is  well  known,  is  impenetrable  to  some  substances,  can  be 
anesthetized.  The  anesthesia  is  not  dependent  upon  the  power  of  absorption  of 
this  membrane,  which  usually  plays  a  passive  role,  but  upon  the  fact  that  small 
c[uantities  of  the  anesthetic  solution  when  placed  upon  its  surface  diffuse  through 
the  epithelium  and  in  this  way  come  in  contact  with  the  nerve  endings  in  the  sub- 
mucous layers.  The  anesthesia,  as  a  rule,  does  not  extend  beyond  the  submucosa. 
The  application  of  cocain  solutions  is  made  by  painting  the  surface,  by  means  of 
cotton  tampons  saturated  with  the  solution,  by  using  fine  sprays,  by  instillations 
into  the  eye,  and  by  injections  into  the  urethra  and  bladder. 

The  necessary  concentration  for  suitable  anesthesia  depends  upon  the  manner  in 
which  the  solution  can  be  applied  to  the  mucous  membrane.  If  the  parts  are 
anesthetized  by  painting,  the  application  of  tampons,  or  by  means  of  the  spray,  very 
concentrated  solutions  (10  to  20  per  cent.)  will  be  necessary  if  it  is  expected  to 
obtain  a  rapid  anesthesia  and  one  of  sufficient  duration.  Instillations  into  the  eye 
and  injections  into  the  urethra  can  be  made  with  much  weaker  solutions,  as  the 
contact  between  the  mucous  membrane  and  the  anesthetic  is  much  more  prolonged. 

iVnesthesia  of  the  bladder  can  be  made  just  as  satisfactorily  with  weak  solutions 
as  with  the  more  concentrated,  if  the  former  are  allowed  to  remain  in  contact  with 
the  surface  for  a  sufficient  length  of  time. 

Attention  has  already  been  directed  to  the  fact  that,  to  avoid  cocain  poisoning, 
no  definite  rules  for  dosage  can  be  laid  down,  but  the  extent  of  surface  and  power  of 
absorption  of  certain  areas  must  be  taken  into  consideration    in  determining  the 


THE  VARIOUS  METHODS  OF  USING  LOCAL  ANESTHETIC  DRUGS  147 

concentration  of  the  solution  to  be  used.  Concentrated  solutions  should  never  be 
applied  to  large  nnicous  surfaces;  their  use  should  be  limited  to  circumscribed 
areas. 

The  use  of  suprarenin  is  of  much  value  in  anesthesia  of  the  mucous  membranes. 
It  is  possible  with  this  addition  to  use  highly  concentrated  cocain  solutions  in 
laryngology,  rhinology,  and  urology  without  secondary  effects  hitherto  impossible. 
Swain,  and  later  Burkofzer,  who  were  the  first  to  introduce  this  agent  in  the  practice 
of  laryngology,  directed  attention  to  this  valuable  property  of  suprarenin,  which 
they  termed  "Kokainsparer."  According  to  Moure  and  Brindel  a  3.5  per  cent, 
cocain  solution  with  the  addition  of  suprarenin  is  sufficient  for  anesthesia  of  the 
larynx  and  nasal  mucous  membrane.  Burkofzer  and  Rode  stated  that  a  5  per  cent, 
solution  with  the  addition  of  suprarenin  should  be  used.  Howe\'er,  with  either  of 
these  solutions  an  anesthesia  of  such  intensity  and  duration  will  be  obtained  as  has 
never  previously  been  known.  The  substitution  of  other  substances  for  cocain  are 
discussed  on  pages  126  to  128.  Regarding  the  chilling  of  mucous  membranes  as 
an  aid  to  local  anesthesia  and  the  use  of  the  ethyl  chloride  solutions  containing 
basic  cocain,  see  pages  96  and  131. 

The  local  action  of  cocain  when  applied  to  other  permeable  membranes  is  similar 
to  its  action  on  mucous  membranes.  The  peritoneum,  the  peritoneal  co^'ering  of 
hernial  sacs,  and  the  tunica  vaginalis  can  be  made  insensitive;  the  first  by  applying 
anesthetic  solutions  to  the  surface  after  opening  the  abdomen  (Schleich  recom- 
mends tropacocain  in  substance  for  this  purpose).  The  latter  can  be  anesthetized 
by  injecting  a  quantity  of  the  anesthetic  solution  into  the  scrotal  sac.  The  use  of 
cocain  for  this  purpose  is  not  necessary  and  should  be  avoided.  If  the  scrotal  sac  is 
filled  with  a  0.5  to  1  per  cent,  novocain-suprarenin  solution,  the  tunica  will  rapidly 
become  insensitive. 

Joint  cavities  can  readily  be  made  insensitive  by  injecting  into  them  anesthetic 
solutions  (Reclus,  Lorenz,  and  von  Hacker).  This  can  be  practically  applied  in  the 
aspiration  and  washing  of  joint  cavities  in  hydrarthrosis  for  the  injection  of  iodine 
and  iodoform  in  tuberculosis  of  the  joints.  Lorenz  was  able  to  forcibly  correct  a  flat 
foot  after  injecting  an  anesthetic  solution  into  the  tarso-crural  joint.  We  will  later 
study  anesthesia  of  the  syno^•ial  membranes  by  injection  into  the  joints  as  a  means 
of  making  them  insensitive  for  operation.  Conway  and  Quenu  have  shown  how 
readily  a  dislocated  joint  can  be  reduced  following  the  intra-articular  injection  of 
anesthetic  solutions. 

Fresh,  granulating  wound  surfaces  and  freely  exposed  nerve  trunks  can  be  anes- 
thetized by  the  superficial  application  of  an  anesthetic  agent.  In  the  first  case 
orthoform  or  some  of  the  newer  preparations — anesthesin,  zycloform,  or  propiisin — 
can  be  used. 


148  LOCAL  ANESTHESIA 

2.     ELECTRIC    CATAPHORESIS    AS    AN    AID    TO    LOCAL    ANESTHESIA. 

The  unbroken  human  skin  is  impenetrable  to  most  substances  in  watery  solutions. 
Drugs  dissolved  in  alcohol,  ether,  or  chloroform  have  slightly  better  powers  of  pene- 
tration (Parisot).  Munk  observed  that  drugs  could  be  introduced  into  the  system 
by  means  of  the  galvanic  current.  The  positive  electrode,  saturated  with  a  strych- 
nin solution,  applied  to  a  rabbit  causes  death  from  strychnin  poisoning  in  about 
five  minutes.  Potassium  iodide  and  quinine  have  been  introduced  in  man  by  this 
means.  This  method,  known  for  some  time  under  the  name  of  cataphoresis,  was 
tried  in  local  anesthesia  by  Wagner  and  Herzog.  Wagner  placed  the  anode 
saturated  with  a  cocain  solution  upon  the  skin  and  found  that  the  latter  became 
insensitive  in  a  few  minutes,  the  intensity  of  this  action  depending  upon  the  con- 
centration of  the  cocain  solution  and  the  strength  of  the  current,  which  was  always 
in  inverse  proportion  to  the  diameter  of  the  electrode. 

With  an  electrode  2.5  cm.  in  diameter,  a  5  per  cent,  cocain  solution  and  a  cur- 
rent of  5  ma.,  it  required  four  to  five  minutes  before  the  skin  became  anesthetic. 
By  interrupting  the  circulation  in  an  extremity,  the  duration  of  the  anesthesia  could 
be  materially  prolonged.  Similar  results  were  obtained  by  Herzog,  Corning,  and 
Peterson.  This  anesthesia  was  limited  to  the  cutis  and  did  not  aft'ect  the  deeper 
lying  parts  such  as  nerve  trunks  (Herzog).  Corning  was  able  to  produce  a  deeper 
anesthesia  by  first  abrading  the  skin  with  an  instrument.  Electrodes  devised  by 
Adamkiewicz,  Stinzing,  and  Peterson  are  particularly  suitable  for  cataphoresis  and 
the  testing  of  the  anesthetic  solutions.  The  electrode  devised  by  iVdamkiewicz  is 
faulty  or,  as  Peterson  has  stated,  "constructed  with  inexcusable  stupidity,"  inasmuch 
as  the  electric  current  does  not  pass  through  the  fluid.  The  author  conducted  a 
number  of  experiments  with  cocain-suprarenin  solutions  but  has  not  been  able  to 
determine  that  the  method  was  of  sufficient  value  to  warrant  its  more  extensive 
use.  He  has  also  attempted  to  produce  a  deeper  anesthesia  by  means  of  the  galvanic 
current  applied  to  solutions  of  cocain  injected  subcutaneously.  It  can,  therefore, 
be  said  that  the  practical  application  of  cocain  cataphoresis  is  of  \cry  little  value. 
Corning  and  Peterson  used  this  method  in  cases  of  hyperesthesia  and  neuralgia; 
Harris  used  it  for  ignipuncture.  More  recent  investigations  by  Peterson  have  shown 
that  minor  operations  can  be  carried  out  without  pain  by  the  use  of  a  10  to  20  per 
cent,  cocain  solution  applied  with  the  anode.  Cataphoric  applications  of  cocain 
solutions  and  cocain-guaiacol  solutions  have  been  used  for  some  time  in  dentistry 
for  the  purpose  of  making  dentine  and  extraction  painless.  The  results  of  this 
procedure,  notwithstanding  the  praise  given  it  by  many  operators,  have  not  been 
very  brilliant  (see  monograph  of  Dorn).  More  recently  Albrecht  has  used  cocain 
cataphoresis  with  apparent  success  for  anesthesia  of  the  ear-drum. 


THE  VAinOrS  METHODS  OF  ('SING  LOCAL  ANESTHETIC  DRUGS  149 


3.     INFILTRATION    ANESTHESIA. 

Infiltration  anestliesia  is  a  form  of  terminal  anesthesia  bronght  about  by  satu- 
rating the  tissues  with  anesthetic  solutions.  By  the  use  of  suitable  drugs  the 
ner\-e  elements  lying  in  the  infiltrated  tissues  become  functionless.  If  the  injected 
solutions  contain  large  quantities  of  the  anesthetic,  the  anesthesia  is  diffused  for  some 
distance  beyond  the  infiltrated  area.  This  secondary  anesthesia  is  known  as  indirect 
infiltration  anesthesia  (see  page  73).  The  action  of  the  anesthetic  is  always  due 
to  its  contact  with  the  sensory  nerve  elements.  The  term  "infiltration  anesthesia" 
originated  with  Schleich;  the  method,  however,  as  described  by  him  differed  from  the 
older  methods  only  in  the  use  of  more  dilute  cocain  solutions. 

Solutions  of  cocain  were  used  originally  almost  entirely  for  infiltration  anesthesia 
in  connection  with  the  so-called  indirect  infiltration  anesthesia.  Various  "depots"  of 
concentrated  cocain  solutions  were  injected  into  the  tissues  and  by  means  of  the 
Esmarch  bandage  the  entire  field  of  operation  was  made  anesthetic.  It  has  been 
pre\'iously  mentioned  on  page  76,  shortly  after  the  introduction  of  cocain,  that 
for  cutting  the  tissues  many  surgeons  held  that  it  was  necessary  to  completely  infil- 
trate the  tissues  with  cocain  solutions  if  a  reliable  result  was  to  be  obtained,  Roberts, 
in  1885,  and  later  Reclus  and  Schleich,  used  infiltration  of  the  skin  in  the  form  of  a 
series  of  skin  wheals  in  the  entire  proposed  line  of  incision.  The  advancement  in 
technical  detail  of  infiltration  anesthesia  is  due  to  Reclus  and  Schleich ;  their  methods, 
at  least  in  principle,  cannot  be  separated  from  one  another.  The  technique  of 
Reclus  and  his  pupils,  Auber,  Fillion,  Legrand,  Kendirdjy,  and  Piquand,  have  been 
known  since  their  numerous  experiments  in  1889.  This  technique,  in  short,  consisted 
in  making  injections  into  the  skin  with  cocain  solutions  throughout  the  entire  extent 
of  the  incision,  and  infiltrating  in  a  similar  manner  all  tissue  layers  to  be  cut.  Reclus 
in  1893  used  a  1  per  cent,  cocain  solution  for  injection,  later  reducing  this  to  0.5  per 
cent.  He  did  not  depend  upon  the  diffusion  of  the  cocain  solution,  relying  only 
upon  direct  infiltration.  Reclus,  from  the  very  beginning  of  his  method,  did  not  con- 
fine its  use  to  minor  surgery  but  recommended  it  for  various  major  operations,  such 
as  herniotomies,  resection  of  the  ribs,  and  many  others. 

According  to  his  experience  in  more  than  7000  cases  the  method  was  apparently 
without  danger,  provided  the  rules  already  mentioned  on  page  93  were  observed, 
a  dose  of  0.2  not  being  feared.  Ceci,  who  used  a  0.5  per  cent,  cocain  solution  for  infil- 
trating the  skin,  found  anemia  of  the  brain  and  psychical  excitation  in  only  1 
case  out  of  4054,  no  other  symptoms  of  cocain  poisoning  were  observed.  For  these 
reasons  we  cannot  agree  with  the  statement  of  Schleich  that  the  danger  from  cocain 
anesthesia,  used  according  to  rule,  is  greater  than  that  of  chloroform  anesthesia. 


150  LOCAL  ANESTHESIA 

The  infiltration  method  of  Recliis  was  later  introduced  into  Germany  but  not  used 
to  any  great  extent  owing  to  the  fact  that  for  extensive  operations  comparatively 
large  doses  of  cocain  were  necessary,  and  because  Schleich  had  shown  that 
more  extensive  anesthesia  of  the  tissues  could  be  obtained  than  heretofore  by  the 
use  of  very  dilute  solutions.  It  requires  but  little  thought  to  separate  this  simple 
and  important  fact,  to  which  we  are  indebted  to  Schleich,  from  numerous  hypo- 
thetical embellishments  suggested  by  this  author.  Schleich,  about  1891,  reported  224 
operations,  including  herniotomies  and  laparotomies,  performed  with  a  0.2  per  cent, 
cocain  solution  in  combination  with  the  ether  spray,  a  dosage  of  0.04  cocain  not 
being  exceeded.  He  claimed  that  the  cooling  of  the  skin  was  only  of  importance  in 
preventing  pain  from  the  insertion  of  the  needle.  We  now  know  that  cooling 
by  means  of  the  ether  spray  produces  a  marked  increase  in  the  action  of  cocain. 
In  the  monograph  by  Schleich,  which  appeared  in  1894,  the  use  of  ether  or  ethyl 
chloride  sprays  was  considered  an  essential  part  of  infiltration  anesthesia. 
Schleich  used  3  different  cocain  solutions  for  infiltrating  the  tissues: 

No.  1 

Cocain  muri 0.2 

Natri  chlorati 0.2 

Morphini  muriat 0.02 

Aquse  dest 100.0 

No.  2 

Cocain  mur 0.1 

Natri  chlorati 0.2 

Morphini  muriat 0 .  02 

Aquae  dest 100.0 

No.  3 

Cocain  mur 0.01 

Natri  chlorati 0.2 

Morphini  muriat 0 .  005 

Aquse  dest 100.0 

The  No.  2  solution,  containing  0.1  of  cocain,  was  the  one  most  frequently  used 
(95  per  cent,  of  all  cases).  Solution  No.  1  was  used  for  anesthetizing  inflamed 
hyperemic  tissues.  Solution  No.  3,  containing  0.01  of  cocain,  was  only  used  when 
the  maximum  dose  had  already  been  given  with  the  other  solutions,  also  for  the  infil- 
tration of  less  sensitive  nerves  and  tissues.  According  to  Schleich  it  was  very  rarely 
necessary  to  use  a  0.5  per  cent  cocain  solution  for  infiltration  of  hyperesthetic  areas. 
The  above-mentioned  solutions  were  prepared  by  Schleich  from  the  following  observa- 
tions. He  found  in  testing  skin  wheals  that  water  with  the  addition  of  0.2  per  cent, 
salt  caused  anesthesia  in  the  infiltrated  tissues,  whereas  a  0.75  per  cent,  salt  solution 
left  sensation  intact.  He  also  observed  that  the  action  of  very  weak  cocain  solutions 
was  much  more  complete  when  this  agent  was  dissolved  in  water  or  in  a  0.2  per  cent. 


THE  VARIOUS  METHODS  OF  VSIXG  LOCAL  ANESTHETIC  DRUGS  151 

salt  solution  than  w  hen  pinsiological  salt  solution  was  used  as  a  solvent.  Beeause 
pure  water  produced  a  se\'ere  irritation  ui)on  injection  he  added  0.2  per  cent,  of 
salt  to  his  solutions.  In  regard  to  the  solutions  which  Schleich  has  termed  "indifferent 
solutions,"  he  has  drawn  the  following  conclusions:  "Anesthesia  is  spread  by  means 
of  the  solution,  it  being  a  pureh-  jihysical  process,  the  chemical  factors  only  coming 
in  for  consideration  in  relieving  the  pain  of  injection.  Water>'  solutions  above  all 
others  produce  the  best  anesthesia." 

Artificial  edema  itself  acts  as  an  anesthetic  by  causing  pressure  on  the  ner\e  sub- 
stance, anemia  of  the  tissues,  and  a  difference  in  temperature  between  the  body  and 
the  solution.  (Schleich  recommended  the  use  of  cold  cocain  solutions  for  injection.) 
In  this  connection  Schleich  himself  observed  that  the  infiltration  of  the  tissues  with 
physiological  salt  solution  did  not  alter  sensation.  Heinze  and  the  author  have 
infiltrated  the  tissues  to  the  point  of  distention  with  an  indifferent  isosmotic  0.9 
per  cent,  salt  solution,  warm  or  cold,  never  obtaining  a  diminution  of  sensation 
but  frequently  a  hyperesthesia.  It  can  therefore  be  said  that  the  artificial  edema 
of  the  tissues  not  only  does  not  produce  anesthesia,  but  usually  increases  the 
excitability  of  the  nerves.  The  forcible  injection  in  a  circumscribed  area  of  about 
0°  degree  solution  can  produce  a  local  anesthetic  effect  by  causing  a  local  anemia 
and  a  diminution  in  the  \itality  of  the  tissues.  This  has  already  been  referred 
to  in  Chapter  VIII,  in  which  the  increased  action  of  anesthetic  solutions  injected 
as  just  described  was  fully  discussed.  It  appears  \'ery  doubtful  to  the  author's 
mind  whether  this  method  is  of  any  great  value;  at  any  rate  the  action  of  the 
injections  upon  the  tissues  is  not  a  physical  one.  The  only  physical  effect  to 
be  noted  in  connection  with  the  injection  of  Schleich's  solution  is  a  diminished 
sensation  due  to  tissue  swelling,  the  solution  causing  a  certain  degree  of  tumefaction 
anesthesia  (see  page  60) .  The  intensity  of  the  anesthesia  depends  upon  the  freezing- 
point  of  the  solution.  The  freezing-point  of  solution  Xo.  1  is  —0.156°,  No.  2  is  —0.145°, 
and  the  third  solution  is  similar  to  a  0.2  per  cent,  salt  solution  being  —0.13°.  In 
Fig.  4,  page  59,  the  solutions  are  placed  in  their  relative  position  on  the  curve.  The 
injection  of  0.2  per  cent,  salt  solution  into  the  cutis  not  only  produces  paresthesia, 
as  suggested  by  Schleich,  but  the  se^•ere  pain  of  tumefaction.  This  can  be  avoided 
by  the  addition  of  0.04  per  cent,  of  cocain,  but  not  by  solution  Xo.  3,  containing 
0.01  per  cent,  of  cocain. 

These  secondary  effects  must  be  less  when  using  solutions  Xos.  1  and  2,  as  their 
freezing-point,  in  consequence  of  the  addition  of  cocain  and  morphin,  are  quite 
different  from  that  of  pure  water.  In  contrast  to  the  marked  anesthetic  power  of  a 
0.1  per  cent,  and  0.2  per  cent,  cocain  solution,  the  physical  secondary  effects  are  of 
the  smallest  practical  importance,  and  it  would  be  a  most  uncertain  state  of  affairs 
if  we  were  to  attribute  the  anesthesia  of  the  Schleich  solution  to  its  physical  effects. 


152  LOCAL  ANESTHESIA 

aiKl  the  Reclus  infiltration  anesthesia  to  the  effect  of  cocain.  All  these  solutions 
produce  anesthesia  owing  to  their  cocain  content,  and  the  author  has  been  able 
to  determine  experimentally  that  there  is  no  difference  in  the  anesthetic  power  of 
cocain,  even  as  dilute  as  0.02  per  cent.,  whether  dissolved  in  a  0.2  per  cent,  or  in  a  0.8 
per  cent,  salt  solution.  Heinze  and  Legrand  have  not  been  able  to  determine 
the  slightest  difference  in  the  anesthetic  property  of  a  Xo.  2  Schleich  in  a  watery 
solution  or  0.8  per  cent,  salt  solution.  The  cocain  anesthesia  is  so  marked  in  the 
experiments  as  to  interfere  with  the  observance  of  any  perceptible  tumefaction  anes- 
thesia, and  it  is  only  when  solutions  of  cocain  are  very  dilute  that  it  can  be  noticed. 
In  watery  cocain  solutions  of  0.01  per  cent.,  cocain  anesthesia  cannot  be  noticed,  the 
solution  acting  as  a  pronounced  irritant  and  showing  anesthetic  properties  similar 
to  that  of  pure  water.  Solutions  of  0.01  per  cent,  cocain  in  0.8  per  cent,  salt  solution 
produce  a  slight  cocain  anesthesia  of  short  duration  without  irritation;  solutions  of 
0.01  per  cent,  cocain  in  0.2  per  cent,  salt  solution  or  Schleich  solution  Xo.  3  show  a 
slightly  more  intense  anesthetic  action.  In  the  latter  we  see  a  combination  of 
cocain  and  tumefaction  anesthesia.  The  injection  is  painful  and  the  cocain  anes- 
thesia cannot  prevent  the  pain  of  tumefaction. 

Schleich's  physical  hypothesis  is  dependent  upon  this  practical  but  unimportant 
difference  which  can  only  be  determined  by  the  most  experienced  observer. 
Because  watery  solutions  have  a  freezing-point  similar  to  0.2  per  cent,  salt  solution 
they  will  cause  a  destruction  of  red-  and  white-blood  corpuscles,  or  their  injection  into 
the  tissues  may  cause  a  tumefaction  necrosis.  For  this  reason  it  is  advisable  onl}" 
to  use  injections  which  have  been  made  indifferent  by  the  addition  of  0.8  to  0.9  per 
cent.  salt.  In  this  way  the  desired  anesthesia  can  be  obtained  without  the  practically 
unimportant  physical  effects  of  the  Schleich  solution.  The  use  of  salt  solution  for 
injections  into  the  tissues  will  therefore  exclude  the  physical  and  limit  the  anesthesia 
to  the  specific  action  of  cocain. 

In  1898  the  author  clearly  stated  that  the  addition  of  morphine  to  the  local  anes- 
thetic was  not  of  the  slightest  value  in  Schleich's  solution,  which  statement  has  been 
verified  by  Heinze,  Custer,  and  Gradenwitz.  The  diminution  of  after-pains,  which 
Schleich  attributes  to  the  addition  of  morphin,  can  only  be  of  central  origin  and  are 
not  due  to  any  local  effect  of  this  substance.  For  this  reason  it  is  better  to  inject  the 
morphin,  if  it  is  considered  necessary,  in  another  part  of  the  body  rather  than  im- 
mediately into  the  operative  field ;  or  it  may  be  administered  before  operation,  as  has 
been  recommended  by  many  surgeons,  so  as  to  increase  the  duration  and  intensity 
of  the  local  anesthetic  or  diminish  the  after-pains. 

The  use  of  0.01  to  0.1  per  cent,  cocaine  in  0.8  per  cent,  salt  solution,  the  object 
of  the  latter  being  to  prevent  swelling  of  the  tissues,  acts  in  exactly  the  same  manner 
as  the  Schleich  solution  with  morphin.    Hackenbruch,  Gottstein,  Legrand  and  others 


] 


J 


THE  VARinrs  METHODS  OF   USING  LOCAL  ANESTHETIC  DRCCS         loS 

have  reenmniended  niixturcs  of  oucain  and  cocaiii  for  the  i)uri)ose  of  utinziiiy-  the 
less  toxic  efi'eet  of  eiieain  and  at  the  same  time  retaining  the  efi'ect  of  coeaiii  in 
contraction  of  the  bkxxhessels.  Schleicii  also  ns(Ml  mixtures  of  cocain  and  alyi)in. 
In  reference  to  the  other  substitutes  for  cocain  up  to  the  time  of  the  introduction 
of  novocain,  see  the  previous  chapter. 

The  saturation  of  the  tissues  with  anesthetic  solutions  is  carried  out  in  layers, 
according  to  the  recommendation  of  Reclus  and  Schleich,  and  is  made  from  without. 
The  anesthesia  is  begun  by  the  injection  of  successive  wdieals  throughout  the  entire 
length  of  the  proposed  incision  (see  Chapter  X),  then  just  before  cutting  the  skin  the 
subcutaneous  connective  tissue  is  injected  in  the  same  direction.  When  using  a  0.5 
to  1  per  cent,  cocain  solution,  it  should  be  given  as  sparingly  as  possible.  When  using 
the  Schleich  solution,  the  anesthetic  zone  is  injected  from  two  wheals  at  the  ends  of  the 
proposed  incision,  and  the  subcutaneous  connective  tissue  so  saturated  that  the  field 
of  operation  is  raised  above  the  surrounding  surface  of  the  skin  in  the  shape  of  a 
huge  boil.  The  skin  and  subcutaneous  connective  tissue  can  now  be  cut  without  pain. 
In  some  cases  Schleich  infiltrates  for  some  distance  beyond  the  subcutaneous  con- 
nective tissue  before  beginning  the  operation.  After  infiltrating  the  subcutaneous 
connective  tissue  according  to  the  method  of  Schleich  the  parts  become  edematous 
and  the  injected  fluid  flows  in  part  from  the  cut  surface.  After  incising  the  tissues, 
as  above  mentioned,  the  other  layers  are  successi\ely  injected  before  cutting,  using 
small  quantities  of  0.5  to  1  per  cent,  cocain  solution  or  larger  quantities  of  the  dilute 
Schleich  solution.  Xer\-e  trunks  crossing  the  field  of  operation,  particularly  when 
using  the  Schleich  solution,  must  be  anesthetized  in  a  manner  which  will  be  described 
later.  The  periosteum,  according  to  Schleich,  becomes  rapidly  insensitive  if  the  sub- 
periosteal tissue  be  infiltrated  with  dilute  cocain  or  eucain  solutions  and  can  then 
be  cut  or  separated  from  the  bone.  Periosteal  injections  are  often  difficult,  sometimes 
impossible. 

Bone  can  be  cut  without  pain  if  the  subperiosteal  infiltration  has  been  carefully 
performed  and  made  sufficiently  extensive.  This  only  applies  to  bones  with  sensory 
nerve  trunks,  like  the  upper  and  lowxr  jaw,  as  these  iktx  t's  retain  their  sensation 
following  the  use  of  the  Schleich  solution.  Direct  mechanical  infiltration  of  bone 
is  impossible.  Dzierzawsky  has  demonstrated  that  colored  solutions  injected  beneath 
the  periosteum  penetrate  the  bone.  This  is  certainly  not  due  to  mechanical  infil- 
tration but  rather  to  a  process  of  diflfusion.  To  produce  anesthesia  of  the  nerve 
elements  in  th  ebone  it  is  necessary  to  use  highly  concentrated  cocain  solutions  for 
injection  beneath  the  periosteum.  Dilute  cocain  solutions  cause  just  as  little  effect 
in  their  distal  action  on  bone  as  dilute  color  solutions.  Mucous  membranes  are 
rendered  insensitive  by  infiltration  of  the  submucous  connective  tissue.  In  order 
to  remove  a  tumor  from  the  submucous  tissues  all  of  the  surrounding  tissue  bordering 


154  LOCAL  ANESTHESIA 

the  tumor  must  be  made  insensiti^'e,  or,  as  Reclus  states,  it  must  be  surrounded 
by  an  atmosphere  of  cocain.  According  to  Schleich,  the  skin  over  the  entire 
extent  of  the  proposed  incision,  be  it  straight,  curved,  or  oval,  must  be  infiltrated  on 
all  sides  of  the  tumor  with  curved  needles,  so  that  the  neighboring  tissues  become 
filled  with  dilute  cocain  solutions.  Schleich  anesthetizes  the  parts  for  opening  an 
abscess  or  furuncle  by  first  infiltrating  the  tissues,  such  as  subcutaneous  connective 
tissue,  fascia,  and  muscle  which  are  not  inflamed  but  surround  the  inflammatory 
area,  and  last  of  all  before  incising  the  abscess  the  inflamed  tissues  themselves  are 
infiltrated.  The  use  of  solutions  very  near  the  lowest  border  of  activity  of  cocain 
has  been  advocated  by  surgeons  universally  for  infiltration  anesthesia  and  the  way 
has  been  opened  for  the  use  of  such  solutions  in  abdominal  operations. 

These  dilute  solutions  for  infiltrating  the  tissues,  according  to  Schleich,  have 
their  advantages  and  disadvantages.  The  advantage  consists  in  the  fact  that 
much  less  cocain  is  used;  the  disadvantage  being  that  the  tissues  are  not  rendered 
perfectly  insensitive  and  the  duration  of  the  anesthesia  is  quite  short,  so  that  in 
operations  of  some  length  the  skin  becoriies  sensitive  before  their  conclusion  and 
must  again  be  infiltrated. 

The  ability  to  anesthetize  areas  with  very  dilute  solutions  must  be  considered  an 
advantage,  but  this  infiltration,  according  to  the  method  of  Schleich,  is  not  always 
possible  and  does  not  always  produce  complete  anesthesia  in  the  field  of  operation, 
many  of  the  sensory  tracts  retaining  their  sensation.  If  the  skin  and  subcutaneous 
connective  tissue  are  cut  immediately  after  infiltration  with  a  0.1  per  cent,  cocain 
or  eucain  solution,  even  though  the  tissues  are  swollen  and  edematous,  the  parts  are 
not  always  completely  anesthetic.  Closer  investigation  will  show  that  the  nerves 
accompanying  the  bloodvessels  in  the  thicker  layers  of  the  tissue  remain  painful  to 
cutting,  pressing,  pulling,  or  grasping  with  instruments.  This  pain  is  described 
as  slight  by  some  patients,  whereas  others  complain  very  bitterly.  It  is  a  mistake 
to  draw  conclusions  from  experiments  on  the  skin,  as  other  tissues,  such  as  sub- 
cutaneous connective  tissue,  do  not  possess  sensation  but  serve  merely  the  purpose 
of  transmitting  the  sensory  nerve  trunks.  It  is  impossible  to  infiltrate  all  the 
tissues  equally,  as  can  be  noted  in  the  skin  by  injections  into  the  subcutaneous 
connective  tissue.  The  injected  fluid  follows  the  course  of  least  resistance,  filling  the 
spaces  between  the  tissues  and  penetrating  the  connective  tissue  containing  blood- 
vessels and  nerves  just  as  little  as  it  does  the  fascia  and  skin.  It  is  only  under  patho- 
logical conditions  of  inflammation  and  chronic  infiltration,  where  the  skin  and  sub- 
cutaneous connective  tissue  assume  a  more  or  less  similar  consistency,  that  these 
parts  can  be  infiltrated  by  injections  into  the  subcutaneous  connective  tissue.  After 
cutting  the  tissues  the  painful  points  can  be  touched  with  a  5  per  cent,  carbolic  acid 
solution   (Schleich),  or  again   infiltrated  with  the  anesthetic  solution,  but  this,  of 


I 


THE  VARIOUS  METHODS  OF  rSING  LOCAL  A\ ESTHETIC  DRUGS  155 

courso.  should  only  hv  done  if  the  i)ati('iit  has  t;iv('n  (.'xprcssioii  of  pain.  The  hiruvr 
lUTX'o  trunks  in  the  operative  field,  the  j)osition  of  whieh  is  determined  from  our  ana- 
tomical knowledge,  must  be  sought  and  properly  treated.  The  muscles  act  similarly  to 
the  subcutaneous  connective  tissue,  for  which  reason  an  e\'en  saturation  with  fluid  is 
impossible.  The  solution  is  forced  between  the  muscle  fibers  but  does  not  penetrate 
the  thick  connective-tissue  septa  containing  the  blood^'essels  and  nerves.  The  cut- 
ting of  muscles  immediately  after  infiltration  with  very  dilute  cocain  solutions  is 
frequently  painful.  A'on  ?>iedlander,  who  has  always  expressed  much  enthusiasm  for 
the  infiltration  of  Schleich,  stated  that  it  was  never  possible  for  him  to  make  an 
entire  muscle  insensitive. 

The  action  of  anesthetic  solutions  on  nerve  trunks  passing  through  tissues  which 
have  been  infiltrated  can  be  explained  by  the  writer's  experiments  upon  the  fingers. 
If  the  subcutaneous  tissues  at  the  base  of  a  finger  are  infiltrated  circularly,  the 
sensory  nerves  will  lose  their  conductivity  as  soon  as  the  entire  finger  becomes 
insensiti\'e.  If  this  does  not  occur,  the  infiltrated  subcutaneous  connecti^'e  tissue 
has  not  been  made  insensitive.  It  has  been  shown  that  the  action  of  a  0.1 
to  0.2  per  cent,  cocain  solution  is  so  slight  that  larger  nerve  trunks  frequently 
are  not  made  insensitive.  It  also  requires  considerable  time  before  a  nerve  trunk 
passing  through  infiltrated  tissues  becomes  insensitiAC.  These  conditions  can  be 
changed  by  increasing  the  concentration  of  the  anesthetic  solutions  or  by  the  use 
of  a  ligature  around  the  extremity.  The  addition  of  suprarenin  or  chilling  the 
parts  renders  anesthetic  action  much  more  rapid  and  interrupts  the  sensory  tracts 
with  much  more  certainty.  The  conductivity  of  nerves  is  ne\er  immediately  inter- 
rupted, even  with  the  use  of  0.5  to  1  per  cent,  cocain  solutions,  with  the  addition  of 
suprarenin  or  ligation  of  the  extremity;  so  if  the  skin  of  the  finger  and  its  subcu- 
taneous connective  tissue  ha\'e  been  infiltrated  with  0.1  per  cent,  cocain  solution 
the  sensation  of  the  subcutaneous  connective  tissue  will  be  retained.  For  these 
reasons  the  old  belief  that  the  Schleich  solution  containing  0.01  per  cent,  of 
cocain  was  supposed  to  be  useful  for  infiltrating  tissues  containing  nerve  tracts, 
is  highly  problematical.  Tissues  which  become  anesthetic  following  injections 
with  these  dilute  solutions  in  all  probability  would  not  have  required  infiltration 
at  all.  In  parts  of  the  body  which  contain  only  the  sensory  nerve  endings  and  no 
nerve  trunks  as,  for  instance,  in  the  median  line  of  the  abdomen  and  neck,  the  dilute 
solutions  of  Schleich  are  very  satisfactory,  but  if  the  tissues  injected  contain  larger 
nerve  trunks,  it  is  a  A'ery  uncertain  and  difficult  procedure  to  hunt  for  each  one  of 
these  nerves  and  inject  them  separately.  Nevertheless,  this  is  necessary  for  producing 
anesthesia  in  these  areas. 

These  disadvantages  may  be  partially  overcome  by  the  observance  of  certain  rules, 
the  first  and  most  important  of  which  is  to  wait  after  infiltration  until  anesthesia 


156  LOCAL  ANESTHESIA 

occurs.  It  is  a  mistake  to  attempt  to  cut  tissues  immediately  after  infiltratiou,  as 
all  tissues  do  not  become  immediately  anesthetic,  as  we  have  observed.  Xo  matter 
where  one  injects,  the  action  of  the  anesthetic  requires  time,  and  its  maximum  effi- 
ciency will  only  be  attained  after  many  minutes  have  passed.  This  circumstance  as 
to  time  was  not  considered  by  either  Reclus  or  Schleich  in  their  technique.  If  the 
tissue  layers  are  successively  infiltrated,  first  infiltrating  and  then  cutting,  it  is  neces- 
sarily impossible  to  wait  the  requisite  time  for  the  action  of  the  anesthetic;  therefore, 
it  is  desirable  to  methodically  infiltrate  the  tissue  layers  before  beginning  the 
operation,  starting  with  the  deepest  and  finishing  with  the  most  superficial  layer, 
so  that  further  injections  during  the  operation  will  be  rendered  unnecessary  (see 
Chapter  IX).  If  this  rule  is  followed,  it  will  be  seen  that  a  separate  infiltration,  as 
for  instance  in  the  skin  and  periosteum,  will  never  be  necessary.  It  is  also  much 
better  in  most  cases  not  to  infiltrate  the  line  of  incision  itself  but  the  area  surround- 
ing the  operati\-e  field  which  contains  the  ner\'es  inner^'ating  the  parts  to  be  cut.  The 
second  rule  is  to  use  such  substances  as  will  cause  a  delay  in  the  parenchymatous 
absorption  of  the  local  anesthesia.  This  is  a  preliminary  measure  which  is  very 
necessary  for  the  success  of  the  technique  to  be  described,  and  is  not  only  intended 
for  small  incisions  but  also  for  extensive  operations  requiring  that  infiltration  be 
thoroughly  reliable. 

CONDUCTION    ANESTHESIA. 

The  ability  of  cocain  to  interrupt  the  sensory  and  motor  nerve  trunks  was  demon- 
strated by  Torsellini,  Feinberg,  Alms,  Kochs,  Witzel,  Mosso,  and  Frank.  The  first 
observations  of  this  kind  made  on  man  originated  with  Corning  and  Goldscheider, 
but  were  only  of  theoretical  interest.  After  ligating  the  upper  arm  Corning  injected 
into  the  trunk  of  the  nervus  cutaneus  antebrachii  lateralis  0.3  c.c.  of  a  4  per  cent, 
cocain  solution  and  immediately  noticed  anesthesia  of  the  skin  supplied  b}'  this  nerve 
as  far  as  the  wrist.  Goldscheider,  without  interrupting  the  circulation,  was  able  to 
obtain  anesthesia  in  the  area  of  distribution  of  a  ner^-e  following  the  subcutaneous 
injection  of  strong  solutions  of  cocain. 

Anesthetic  solutions  can  be  used  in  various  ways  for  anesthetizing  nerve  trunks. 
The  injection  can  be  made  immediately  beneath  the  fibrous  sheath  directly  into  the 
nerve  trunk  (endoneural  injection).  If  the  injected  solution  is  not  too  weak,  almost 
immediate  interruption  of  conductivity  occurs  (Crile).  This  procedure  is  only  possible 
when  the  nerve  trunk  has  been  freely  exposed  before  operation.  Very  few  nerve 
trunks  are  so  situated  and  so  palpable  that  they  can  be  reached  exactly  with  the 
needle  through  the  unbroken  skin.  As  a  rule,  it  is  only  possible  to  inject  the 
solutions  in  the   neighborhood  of   the   nerve   trunks    (perineural   injections).     The 


THE   VARIOVS  METHODS  OF   (',s7A'C;  LOOM.  A  XFSTII ETIC  Dh'VdS  157 

intcrrui)ti()n  of  coiKliiction  hy  this  procedure  rcciuircs  sonic  little  time,  iiiasiimch 
as  the  Ilcr^•e  trunk  is  reached  only  hy  dittusion.  Conduction  anesthesia  can  also 
he  produced  hy  direct  injections  into  the  spinal  canal,  according  to  the  method  of 
liier,  or  by  injections  into  the  ei)idural  space  of  the  sacrum,  according  to  the  method 
of  Cathelin-Laewen.  Intravenous  and  intra-arterial  injections  produce  anesthesia 
not  only  by  their  action  on  tlie  nerve  ends  but  also  on  the  nerve  trunks. 

Perineural  Injections  of  Anesthetic  Solutions. — The  action  of  anesthetic  solutions 
upon  ner\e  trunks  passing  through  tissues  infiltrated  with  anesthetic  solutions  is  in- 
dircH/t.  The  anesthetic  must  difi'use  through  the  connectixe  tissue  layers  surrounding 
the  ner\-e  trunks  before  the  nerve  substance  is  anesthetized.  For  these  reasons  it 
will  be  observed  that  sensory  nevxe  tracts  are  much  more  readily  and  more  quickly 
interrupted  when  the  perineural  injection  is  made  in  the  area  where  the  nerve 
branches  are  very  thin  rather  than  in  the  neighborhood  of  the  beginning  of  the 
nerve  trunk.  For  instance,  in  the  neighborhood  of  the  spinal  cord,  where  it  will  be 
found  that  much  larger  quantities  of  a  more  highly  concentrated  solution  will  be 
necessary  for  the  interruption.  This  is  due  to  the  fact  that  the  nerve  trunk  not 
onh'  increases  in  thickness  toward  its  proximal  end  but  the  thickness  of  its  connec- 
ti^'e  tissue  covering  is  also  increased.  It  will  be  noticed  that  the  action  of  an 
anesthetic  in  the  spinal  canal  is  very  prompt  and  pronounced,  owing  to  the  fact 
that  the  nerve  trunks  are  not  ])rotected  by  this  connective  tissue  covering.  The 
interruption  of  nerve  trunks  by  means  of  perineural  injections  is  used  very  exten- 
sively for  rendering  their  areas  of  distribution  insensitive.  Every  infiltration  of 
connective  tissue  layers  containing  nerve  tracts  produces  not  only  infiltration 
anesthesia  in  the  area  injected,  but  also  conduction  anesthesia  in  the  area  of 
distribution  of  the  nerves  affected. 

The  simplest  form  of  conduction  anesthesia  follows  the  injection  of  anesthetic 
solutions  into  the  subcutaneous  connective  tissue.  Inasmuch  as  the  subcutaneous 
connective  tissue  contains  the  sensory  nerve  tracts  for  the  overlying  skin,  this  struc- 
ture must  of  necessity  be  made  insensitive,  when  the  subcutaneous  connective 
tissue  is  infiltrated  with  an  anesthetic  solution.  It  might  be  thought  that  the  anes- 
thesia of  the  skin  is  produced  by  diffusion  of  the  injected  anesthetic  from  the  subcu- 
taneous connective  tissue,  but  this  is  probably  not  the  case,  as  the  small  quantities 
of  solution  which  would  reach  the  skin  in  this  way  would  make  the  parts  less 
insensitive  than  a  direct  infiltration  of  the  skin  with  the  same  solution.  On  the  con- 
trary, it  will  be  noted  that  solutions  injected  into  the  subcutaneous  connective  tissues 
produce  an  anesthesia  of  the  same  intensity  and  duration  as  that  following  the  intra- 
cutaneous infiltration  of  the  same  solution;  in  fact,  this  effect  is  produced  beyond  all 
doubt  by  interrupting  the  nerves  supplying  the  skin.  In  like  manner  we  speak  of 
the  innervation  of  the  periosteum,  which  takes  place  not  from  the  bone  but  from  the 


158  LOCAL  ANESTHESIA 

tissues  overlying  it;  therefore,  if  these  tissues  be  infiltrated,  both  periosteum  and  bone 
will  be  made  insensitive,  and  subperiosteal  injections  will  be  found  as  unnecessary 
as  the  direct  infiltration  of  the  skin. 

Hackenbruch  has  described  the  so-called  "circular  analgesia,"  which  consists  in 
so  circumscribing  the  operative  field  with  the  anesthetic  solution  that  all  nerve  supply 
to  this  part  will  be  interrupted.  Hackenbruch  used  for  this  purpose  0.25  to  0.5  per  cent, 
cocain  and  eucain  solutions,  but  the  addition  of  the  newer  aids  to  local  anesthesia 
were  necessary  for  progress  with  this  procedure.  Until  the  introduction  of  these  sub- 
stances his  method  of  anesthesia  was  only  ajjplicable  to  the  ligated  extremities.  Oberst 
used  a  similar  method  for  anesthetizing  the  fingers  and  toes.  If  0.5  to  1  per  cent, 
cocain  solution  is  injected  beneath  the  skin  of  the  base  of  the  finger  or  toe  which  has 
been  ligated,  a  complete  transverse  anesthesia  of  the  entire  finger  or  toe  will  follow  in 
a  few  minutes.  The  infiltrated  subcutaneous  connective  tissue  of  the  finger  contains 
many  nerve  tracts;  the  finer  branches  supplying  the  skin  are  rendered  non-conductive; 
the  larger  branches  supplying  the  other  parts  are  affected  by  diffusion.  The  anesthesia 
proceeds  in  this  way  from  the  centre  toward  the  periphery,  the  disappearance  of  sensa- 
tion in  the  finger  tip  indicating  that  all  nerve  trunks  in  the  subcutaneous  connective 
tissue  supplying  the  finger  have  been  interrupted.  In  an  operation  upon  a  finger 
anesthetized  in  this  manner,  all  nerve  trunks  are  found  insensitive.  A  transverse 
incision  can  be  made  in  any  segment  of  the  finger  without  pain.  This  method  was 
used  in  1888  by  Oberst,  but  was  first  described  in  1890  by  Pernice.  It  is  possible  that 
Kummer  and  others  may  have  preceded  these  writers,  but  it  was  not  until  the  author's 
reference  to  this  subject  in  1897,  in  connection  with  a  similar  report  by  Hackenbruch, 
that  this  method  came  into  general  use.  The  first  practical  application  of  the  peri- 
neural injection  of  cocain  for  the  purpose  of  blocking  various  nerve  trunks  at  a  dis- 
tance from  the  operative  field  was  performed  by  Hall  and  Halstedt.  The  first 
mentioned  injected  cocain  into  the  infra-orbital  nerve;  the  latter  into  the  trunk  of 
the  inferior  alveolar  nerve  for  the  purpose  of  extracting  teeth  without  pain. 

The  ligation  of  an  extremity  is  not  absolutely  essential  for  the  anesthesia  of  nerve 
trunks,  as  has  been  shown  in  the  reports  of  Krogius  in  1894,  but  if  this  is  not  done, 
more  highly  concentrated  cocain  solutions  will  be  necessary.  In  reference  to  this 
anesthesia  Krogius  reports  as  follows:  If  one  injects  beneath  the  skin  of  the  dorsum 
or  palmar  surface  of  the  hand  or  the  foot  transverse  lines  of  a  2  per  cent,  cocain 
solution,  the  parts  distal  to  this  injection  will  become  anesthetic,  and  if  the  four  nerves 
supplying  the  fingers  be  anesthetized  by  the  injection  of  1  to  1.5  c.c.  of  a  2  per  cent, 
cocaine  solution,  the  fingers  will  become  totally  anesthetic  in  about  ten  minutes.  It 
is  possible  to  produce  an  analgesia  of  the  ulnar  side  of  the  hand  as  far  as  the  base  of  the 
fourth  or  fifth  finger  by  means  of  an  injection  over  the  ulnar  nerve  where  it  passes 
through  the  groove  on  the  inner  condyle  of  the  humerus.    If  an  injection  is  made  in 


I 


rilE  VARIOrS  METHODS  OF  USING  LOCAL  ANESTHETIC  DRUGS  159 

the  lunghborhood  of  the  supraorbital  foramina  analgesia  of  the  entire  mid-portion 
of  the  forehead  will  oecur.  Injeetions  around  the  base  of  the  penis  will  render  the 
foreskin  entirely  insensitive.  This  method  is  of  little  practical  use  for  operations  upon 
the  arms  or  legs,  and  has  not  been  of  any  value  in  operations  in  the  gluteal  region. 
This  analgesia  reaches  its  maximum  intensity  and  extent  after  from  five  to  ten  min- 
utes and  continues  for  a  quarter  of  an  hour  or  longer.  The  effect  of  the  cocain  is 
much  more  satisfactory  if  an  p]smarch  band  is  placed  above  the  area  injected.  The 
abo\e  statements  express  the  experiments  of  Krogius.  The  fact  is,  however,  the  liga- 
tion is  not  necessary  if  0.02  cocain  in  1  to  2  per  cent,  solution  be  injected  into  a  finger 
in  the  method  described,  anesthesia  occurring  in  the  course  of  a  few  minutes  without 
interrupting  the  circulation;  but  the  use  of  the  various  aids  to  local  anesthesia  permit 
of  a  diminution  in  the  dose  of  cocain  and  the  concentration  of  its  solutions  and 
should  be  recommended  as  making  action  more  certain  and  prolonging  the  duration 
of  the  anesthesia.  A  0.1  to  0.2  per  cent,  cocain  solution  injected  circularly  beneath 
the  skin  of  the  basal  phalanx  of  a  finger  will  cause  a  complete  break  in  the  conduc- 
ti^•ity  of  the  nerves.  It  is,  however,  necessary  to  wait  considerably  longer  for  this 
to  occur  than  after  the  use  of  more  concentrated  solutions. 

The  above-mentioned  communications  of  the  author  have  been  the  means  of  stim- 
ulating much  experimental  work  along  these  lines  by  such  men  as  Honigmann,  INIanz, 
Arendt,  Sudeck,  Berndt,  Gerhardt,  Hoelscher,  and  Luxenburger.  They  have  used 
the  method  of  Oberst  for  operations  upon  the  fingers  and  toes  and  have  attempted 
to  increase  the  extent  of  the  conduction  anesthesia  on  the  hand  and  foot  by  applying 
the  methods  already  described  by  Krogius.  ]\Ianz,  after  ligating  the  upper  arm, 
injected  a  0.5  to  1  per  cent,  cocain  solution  into  the  radial,  ulnar,  and  median  nerves 
of  the  forearm,  and  after  ligating  the  leg,  he  injected  the  peroneal  and  tibial  nerve 
just  above  the  ankle.  After  twenty  to  forty-five  minutes  the  hand  and  foot  became 
absolutely  insensitive  so  that  operations  of  any  kind  could  be  carried  out  on  the  hand 
and  foot  without  pain.  Similar  experiments  upon  the  hand  and  forearm  have  been 
reported  by  Berndt,  Hoelscher,  and  Luxenburger.  Berndt  also  described  an  amputa- 
tion, according  to  the  method  of  Gritti,  which  was  performed  without  pain.  Gottstein 
reports  a  PirogoflF  amputation  carried  out  by  this  method.  Arendt  and  Hoelscher 
used  this  same  method  for  operations  upon  the  penis.  Berndt  and  Hoelscher  held 
it  to  be  more  advisable  to  use  larger  quantities  of  dilute  cocain  and  eucain  solutions 
(0.2  per  cent  Hoelscher,  0.05  per  cent.  Berndt)  than  smaller  quantities  of  a  1  per 
cent,  solution,  as  recommended  by  Pernice. 

^lanz  claimed  not  to  have  had  good  results  with  solutions  more  dilute  than  0.5 
per  cent.  Berndt,  believing  that  the  edema  of  the  tissues  produced  by  the  injection 
of  an  indifferent  solution  would  produce  anesthesia,  injected  physiological  salt  solu- 
tions for  this  purpose.     Luxenburger  advised  the  injection  of  2  per  cent,  nirvanin 


160  LOCAL  ANESTHESIA 

solutions  for  anesthesia  of  nerve  trunks.  Hoelscher  belie\ed  that  ner\'e  conductivity 
between  the  proximal  and  central  parts  of  an  extremity  could  be  best  interrupted  by 
infiltrating  all  the  tissues  transversely  with  dilute  solutions  of  cocain.  Practically 
all  observers  are  of  the  opinion  that  considerable  time  is  necessary  for  the  interrup- 
tion of  conductivity  of  the  larger  nerve  trunks  of  an  extremity  except  the  fingers 
and  toes,  and  that  the  ligation  of  the  extremity  cannot  be  dispensed  with,  even  though 
its  application  causes  very  considerable  discomfort  and  pain  to  the  patient  during 
its  use.  It  is  only  in  very  thin  extremities  that  the  pressure  of  the  bandage  necessary 
to  interrupt  the  circulation  is  so  slight  as  not  to  cause  pain. 

Just  how  much  of  the  anesthetic  effect  upon  an  extremity  so  treated  is  to  be  ascribed 
to  the  medicament  injected,  and  how  much  to  the  compression  of  the  nerve  trunks 
from  the  bandage,  Manz  is  unable  to  say;  whereas  Kofmann  claims  that  the  ligation 
is  the  most  important  part  and  the  injection  of  the  anesthetic  solution  is  entirely 
unnecessary.  The  anemia  of  the  tissues  produced  by  ligation  (see  Chapter  III)  affects 
sensation  so  late  that  it  can  hardly  be  considered  an  active  factor  of  the  anesthesia; 
whereas  the  ligation  itself,  if  made  sufficiently  tight,  can  produce  an  interruption  of 
the  conductivity  of  the  nerve  trunks.  It  can  therefore  be  said  that  in  many  of 
the  reported  cases  in  which  anesthesia  is  supposed  to  have  been  produced  by  the 
injection  of  very  dilute  solutions  of  cocain,  or  even  of  normal  salt  solution  follow- 
ing the  injection  of  this  substance  it  was  necessary  to  wait  considerable  time  before 
anesthesia  occurred.  Anesthesia  in  these  cases  was  not  due  to  the  injection  of 
cocain  but  rather  to  the  prolonged  ligation  of  the  extremit}-. 

In  1903  the  writer  reported  some  results  of  experiments  for  producing  conduc- 
tion anesthesia — in  fact,  introduced  the  term  "conduction  anesthesia"  to  physiology 
and  other  related  sciences.  These  experiments  demonstrated  that  by  means  of  the 
injection  of  cocain,  in  connection  with  the  ligation  of  an  extremity  or  the  addition 
of  suprarenin,  the  ulnar,  radial,  median,  tibial,  and  peroneal  nerves  could  be  readily 
interrupted  at  certain  points  and  that  suprarenin  could  replace  ligation.  Following 
the  interruption  of  conductivity,  sensory  and  motor  paralysis  occurred ;  in  the  mixed 
nerves  of  the  extremity  vasomotor  paralysis  followed,  so  that  the  innervated  area 
became  hyperemic  just  as  after  the  cutting  of  the  nerves.  According  to  the  experi- 
ments of  Heidenhain,  the  sensory  nerves  are  usually  affected  before  the  motor  nerves 
and  the  effects  are  also  more  lasting,  so  the  former  can  be  considered  much  more 
sensitive  to  the  anesthetic  than  the  motor  nerves.  The  long  subcutaneous  nerves  of 
the  skin  can  readily  be  interrupted  if  a  transverse  strip  of  subcutaneous  connective 
tissue  is  infiltrated  according  to  the  method  of  Krogius.  On  account  of  the  over- 
lapping of  the  innervated  areas  of  one  nerve  with  another,  it  will  be  necessary  to 
anesthetize  several  nerve  trunks  in  order  to  produce  a  practical  and  useful  peripheral 
conduction  anesthesia.    Owing  to  vasomotor  paralysis  it  may  also  be  necessary  to 


I 


THE  VARIOUS  METHODS  OF  USING  LOCAL  ANESTHETIC  Dh'UCS         1(11 

li.uatc  an  extremity  in  ease  niixiMl  nerves  are  interrupted  near  the  base  of  the 
extremity-.  If  suprareniu  has  been  added  to  the  solution,  it  will  not  be  neeessary, 
while  waitin.u'  for  anesthesia  to  occur,  to  apply  the  ligature  until  just  before  beginning 
the  operation.  Al)sorption  can,  however,  be  still  more  delayed  by  the  ai)plieation  of 
the  (■oni])ressi()n  i)andage. 

The  use  of  suprareniu  renders  conduction  anesthesia  just  as  certain  in  other  parts 
of  the  body  as  in  an  extremity.  We  have  already  spoken  of  the  interruption  of  the 
supraorbital  and  occipital  nerves,  the  cervical  nerves  where  they  pass  from  beneath 
the  posterior  edge  of  the  sternocleidomastoid  muscles,  and  also  the  superior  laryn- 
geal nerves  in  operations  on  the  larynx.  Halstedt  has  already  described  the 
interruption  of  the  inferior  alveolar  and  lingual  nerves.  Another  advancement 
followed  the  introduction  of  novocain,  whereby  indefinite  quantities  of  a  stronger- 
acting  anesthetic  could  be  introduced  without  danger.  All  methods  of  conduction 
anesthesia  were  improved  by  the  introduction  of  this  drug,  such  as  infiltration  of 
tissue  layers  containing  conducting  nerve  tracts,  the  circuminjection  of  operative 
fields,  the  blocking  of  nerve  trunks,  and  better  methods  of  operating  in  the  areas 
supplied  by  the  trigeminus,  in  operations  upon  the  neck,  operations  upon  the  thorax, 
and  in  hernia  in  which  conduction  anesthesia  by  means  of  perineural  injections  is 
most  important.  More  recently  Laewen  has  introduced  the  precutaneous  anesthesia 
of  the  sciatic  and  femoral  nerve,  and  Hirschel  and  Kulenkampff  a  similar  method  for 
anesthetizing  the  brachial  plexus.  More  definite  information  can  be  gained  from  the 
special  chapters  devoted  to  this  subject.  In  general,  however,  it  can  be  said  that 
large  individual  nerve  trunks  are  easily  and  certainly  blocked  by  injection  if  their 
position  can  be  determined  by  bony  landmarks.  IMuch  more  experience  is  necessary 
if  these  nerves  are  situated  in  the  midst  of  soft  parts.  In  the  latter  case  the  radiating 
peripheral  sensations  of  paresthesia  following  the  touching  of  the  nerve  trunks  with 
the  needle  is  the  most  certain  method  of  determining  the  proper  location  of  the  needle, 
so  as  not  to  be  dependent  upon  the  statements  of  the  patients.  Perthes  constructed 
a  needle  covered  with  an  insulating  material  through  which  he  passed  a  faradic 
current;  as  soon  as  the  needle  touched  a  mixed  nerve  contractions  in  the  muscles 
supplied  were  readily  observed. 

Endoneural  Injections  of  Anesthetic  Solutions. — This  method  was  first  described 
by  the  American  surgeons,  C'rile,  Matas  and  Cushing.  It  consisted  in  introducing 
a  needle  into  the  several  nerves  supplying  the  operative  field  and  injecting  a  small 
quantity  of  an  anesthetic  solution  under  the  fibrous  sheath  or  between  the  bundle 
fibers,  in  this  manner  thoroughly  saturating  the  nerve  and  causing  it  to  swell.  By  the 
use  of  proper  solutions  the  conductivity  of  the  nerve  was  instantly  interrupted  just 
as  though  it  had  been  cut  with  a  knife.  For  the  carrying  out  of  this  procedure  it 
is  necessary  in  most  cases  to  freely  expose  the  ner\e  trunk  under  local  anesthesia 
11 


162  .  LOCAL  ANESTHESIA 

at  some  distance  from  the  field  of  operation.  Crile  carried  out  extensive  experiments 
upon  animals  in  reference  to  the  action  of  cocain  and  eucain  when  injected  into 
nerve  trunks  and  found  that  these  drugs  did  not  differ  markedly  from  one  another 
in  their  action.  He  performed  amputation  of  the  leg  five  times  with  this  method 
(the  first  operation  occurring  in  1887);  the  sciatic  nerve  was  exposed  in  the 
gluteal  fold  and  the  femoral  nerve  in  the  inguinal  fold,  and  cocain  or  eucain 
solutions  were  injected  into  the  nerve  trunks.  The  patients,  after  consenting  to 
operation,  were  not  permitted  to  know  what  was  taking  place  so  that  the  psychical 
effect  of  the  amputation  could  be  prevented.  The  interruption  of  the  nerve  trunks 
lasted  twenty-five  to  thirty  minutes.  Matas,  to  whom  credit  for  the  terms  endoneural 
and  perineural  belongs,  carried  out  this  same  procedure  in  operations  upon  the  foot 
and  leg ;  the  popliteal  and  saphenous  nerves  w^re  exposed  and  infiltrated  with  a  cocain 
solution,  whereupon  complete  anesthesia  was  produced  from  the  knee  down.  Matas 
was  able  to  centrally  anesthetize  the  forearm  and  hand  by  infiltrating  the  freely 
exposed  ulnar,  median,  and  radial  nerves,  injecting  into  each  of  them  0.25  to  0.5  c.c.  of 
a  1  per  cent,  cocain  solution.  The  upper  arm  was  then  ligated,  after  which  the  opera- 
tion was  carried  out  and  the  w^ound  sewed  and  dressed.  Sensation  returned  about 
ten  to  fifteen  minutes  after  the  removal  of  the  constricting  band.  Anesthesia  of  the 
brachial  plexus  was  also  attempted  by  Crile.  Under  infiltration  anesthesia  with  a 
0.1  per  cent,  cocain  solution  he  exposed  the  brachial  plexus  and  the  subclavian 
artery  at  the  posterior  end  of  the  sternocleidomastoid  muscle  and  injected  0.5  per 
cent,  cocain  solution  into  each  nerve  trunk,  using  just  sufficient  of  this  solution 
to  cause  a  small  swelling  of  the  nerve.  The  artery  was  temporarily  clamped  and  the 
arm  disarticulated  at  the  shoulder-joint.  The  operation  was  painless  with  the  excep- 
tion of  the  posterior  and  outer  skin  incision.  In  a  similar  manner  Crile  performed 
amputation  in  the  middle  of  the  upper  arm.  He  also  performed  a  disarticulation  of 
the  upper  arm  with  removal  of  the  scapula,  some  general  anesthetic  being  necessary, 
as  was  to  be  expected.  Crile  directed  attention  to  the  fact  that  the  ulnar  nerve 
at  the  elbow  could  very  readih'  be  injected  with  an  anesthetic  solution  without 
previously  dissecting  it  free,  the  interruption  of  conducti^'ity  following  almost  immedi- 
ately after  the  injection.  The  peroneal  nerve  can  be  frequently  injected  at  the 
bend  of  the  knee.  The  trunk  of  the  trigeminus  can  likewise  be  injected  at  the  base 
of  the  skull  as  well  as  the  Gasserian  ganglion. 

The  necessity  for  freely  exposing  nerve  trunks,  as  practised  by  Crile  and  JMatas, 
so  complicates  anesthetic  methods  that  this  will  only  be  done  when  there  are  definite 
contra-indications  to  the  use  of  a  general  anesthetic.  Crile  mentions  as  a  particular 
advantage  of  this,  method  of  anesthesia  that,  with  an  interruption  of  the  conductivity 
of  nerves  from  the  field  of  operation,  shock  does  not  occur.  Cushing  and  other 
American  surgeons  recommend  the  injection  of  the  large  nerve  trunks  before  cutting 


THE  VARIOUS  METHODS  OF  USING  LOCAL  ANESTHETIC  DRUGS  163 

tliem,  t'\  en  wlicn  an  operation  is  carried  out  under  general  anesthesia,  as,  for  instance, 
in  disarticulations  of  the  shouhler.  The  injection  of  anesthetic  solutions  into  freely 
exposed  nerve  trunks  is  a  sure  and  harmless  method  of  anesthesia  and  will  occa- 
sionally be  found  of  use.  This  method  would  be  very  much  simplified  if  it  were 
possible  to  inject  the  nerve  trunks  exposed  through  the  same  incision  as  used  for 
the  operation  itself.  This  method  was  made  use  of  by  Gushing  in  the  operative 
treatment  of  inguinal  hernia.  By  means  of  Schleich's  infiltration  anesthesia  he 
freely  exposed  the  inguinal  canal  and  injected  the  ilioinguinal  and  spermatic  nerves 
^\■hich  lie  under  the  fascia  with  a  1  per  cent,  cocain  solution.  As  the  result  of  this 
injection  the  hernial  sac  and  its  coverings,  the  spermatic  cord,  the  testes,  and  a 
portion  of  the  skin  of  the  inguinal   region  became  insensitive. 

Lumbar  and  Sacral  Anesthesia. — If  an  anesthetic  solution  be  injected  beneath  the 
dura  of  the  lumbar  region  by  means  of  the  lumbar  puncture  described  by  Quincke, 
the  solution  mixes  with  the  cerebrospinal  fluid  and  interrupts  the  conductivity  of  the 
nerve  trunks  of  the  cauda  equina  and  the  roots  of  the  spinal  nerves  (Corning  and  Bier). 

If  by  means  of  the  sacral  puncture  described  by  Cathelin  an  anesthetic  solution 
is  injected  into  the  epidural  space  of  the  spinal  canal  the  anesthetic  will  act  on  the 
spinal  nerves  surrounded  by  the  dura,  passing  from  this  point  to  the  intervertebral 
foramina,  causing  their  interruption  (Laewen). 

Both  lumbar  and  sacral  anesthesia,  as  will  be  readily  seen,  are  forms  of  conduction 
anesthesia.  Their  technique  and  indications  do  not  conflict  with  those  of  local  anes- 
thesia, as  they  have  developed  into  particular  anesthetic  methods  which  in  a  narrower 
sense  are  opposed  to  local  anesthesia,  for  which  reason  we  will  only  mention  these 
methods  without  entering  into  further  detail. 


VEIN    ANESTHESIA. 

In  190S  Bier  devised  a  very  effective  method  for  bringing  anesthetic  solutions  in 
contact  with  nerve  substance.  He  injected  a  solution  of  novocain  into  one  of  the 
subcutaneous  veins,  freely  exposed  between  two  constricting  rubber  bandages,  the 
space  between  which  had  been  previously  rendered  bloodless.  Experimental  inves- 
tigation had  shown  that  the  vein  walls  were  particularly  permeable  to  watery  solu- 
tions. The  injected  solution  permeated  the  entire  section  of  the  limb  very  quickly, 
producing  between  the  two  bandages  a  terminal  anesthesia.  This  Bier  called  "direct 
^■ein  anesthesia."  The  solution  permeates  this  area,  also  those  nerves  passing  to 
other  parts  of  the  limb,  blocking  them  and  gi^'ing  rise  to  indirect  vein  anesthesia 
in  the  entire  portion  of  the  limb  distal  to  the  ligatures.  The  technique  of  vein  anes- 
thesia has  been  described  in  detail  by  both  Bier  and  Haertel,  and  is  as  follows: 
The  entire  extremity  is  sterilized,  elevated,  and  made  bloodless  by  a  rubber  band 


1G4  LOCAL   ANESTHESIA 

carried  from  the  toes  or  fingers  to  aljove  the  place  where  the  injection  is  to  be  made. 
Immediately  above  this  bandage  a  second  rubber  band  is  passed  about  the  extremity. 
The  first  bandage  is  then  removed  for  a  distance  of  about  a  handbreadth  and  not 
more  than  three  handbreadths  from  the  upper  bandage.  At  this  point  the  second 
compression  bandage  is  placed  (Fig.  8).  For  peripheral  portions  of  a  limb  direct 
anesthesia  can  be  carried  out  with  one  constricting  band  which,  however,  should  not 
be  placed  higher  than  the  middle  of  the  forearm  or  leg.    Operations  on  infected  tissues 


Fig.  8. — Ligation  for  vein  anesthesia. 

should  only  be  carried  out  by  indirect  vein  anesthesia.  For  this  purpose  a  com- 
pression band  is  placed  above  the  infected  area,  and  at  this  point  the  bandage  for 
producing  the  anemia  begins.  The  second  compression  bandage  is  then  placed  above 
the  latter.  Just  under  the  upper  constricting  band  one  of  the  larger  subcutaneous 
veins,  such  as  the  cephalic,  basilic,  median,  or  great  saphenous,  is  freely  exposed  under 
infiltration  anesthesia.  In  order  to  render  the  location  of  the  veins  certain  it  is 
advisable,  before  applying  the  bandage  for  producing  the  anemia,  to  mark  the  course 


THE  VARIOUS  METHODS  OF   ISIXO  LOCAL  AX  ESTHETIC  DRUdS  105 

and  ])ositi()ii  of  the  vein,  or  expose  tlie  \eiii  before  ai)i)lyiiii;-  the  l)aiuUige.  The  author 
advises  the  hitter  method,  so  that  the  i)atient  will  not  be  allowed  to  suffer  from  the 
compression  bandage  remaining  unnecessarily  long  upon  the  limb. 

The  syringe  recommended  by  Bier  (Fig.  9)  is  of  100  c.c.  capacity,  connected  with  a 
canula  by  means  of  a  thick-walled  rubber  tube.  The  canula  is  provided  with  a  cock  so 
that  it  may  be  closed,  and  has  two  furrows  at  its  end  for  the  purpose  of  tying  it  into 
the  vein.  The  canula  is  tied  into  the  ^'ein  in  the  same  manner  as  for  salt  infusions, 
except  that  it  is  tied  into  the  peripheral  and  not  the  central  end  of  the  vein.  Injec- 
tions are  made  under  even  pressure,  or,  as  occasionally  happens,  very  strong  pressure, 
until  the  vein  valves  are  overcome,  0.5  per  cent,  novocain  solution  without  suprarenin; 
40  to  50  c.c.  for  the  upper  extremity  and  70  to  100  c.c.  for  the  lower  extremity, 
depending  upon  the  thickness  of  the  limb.  If  during  the  injection  some  of  the 
smaller  branches  are  seen  to  spirt  they  must  be  immediately  closed  with  hemo- 


FiG.  9. — Syringe  for  vein  anesthesia. 

static  forceps.  After  completing  the  injection  the  canula  is  closed  by  means  of 
the  cock  and  the  vein  is  ligated  and  cut,  the  small  wound  being  closed  by  suture. 
Complete  anesthesia  will  occur  throughout  the  entire  transverse  section  of  the  limb 
in  about  five  minutes ;  indirect  anesthesia  as  well  as  complete  motor  paralysis  in  the 
perij:)heral  part  of  the  limb  follows  in  about  five  to  fifteen  minutes.  At  this  time  the 
peripheral  constricting  band  can  be  removed  in  case  it  interferes  with  the  performance 
of  the  operation. 

The  anesthesia  lasts  as  long  as  the  upper  constricting  band  is  kept  in  place.  As 
soon  as  it  is  removed,  sensation  returns  in  a  few  minutes.  According  to  the  observa- 
tion of  Bier,  the  addition  of  suprarenin  to  the  novocain  solution  does  not  prolong  vein 
anesthesia  very  materially,  but  it  frequently  prevents  an  even  distribution  of  the  in- 
jected solution  throughout  the  transverse  area,  for  which  reason  it  should  not  be  used. 


166  LOCAL  ANESTHESIA 

\q\\\  anesthesia  should  be  used  in  suitable  cases  and  is  without  danger.  Poisoning 
from  novocain  need  not  be  feared  following  its  use.  The  cases  most  suitable  for  vein 
anesthesia  are  resection  of  joints  and  amputations  from  about  the  middle  of  the  thigh 
or  upper  arm  downward.  This  method  should  not  be  used  when  operating  for 
diabetic  gangrene  (Bier).  It  is  also  a  question  whether  this  method  should  be  used 
in  septic  infections,  as  it  is  possible  to  open  a  A^ein  which  is  infected,  even  if  some 
distance  from  the  diseased  area. 

The  upper  constricting  bandage  causes  severe  pain  after  a  short  time.  Perthes 
has  devised  a  compressor  which  has  relieved  this  somewhat.  Momburg  advises 
after  anesthesia  has  set  in  that  a  second  compression  bandage  be  placed  in  the  area 
of  direct  anesthesia  and  the  bandage  causing  the  pain  removed.  The  rapid  return 
of  sensation  following  the  removal  of  the  bandage  is  very  inconvenient  in  amputations, 
as  the  operation  must  have  been  previously  completed,  hemostasis  being  rendered 
very  difficult.  The  literature  on  the  subject  of  vein  anesthesia  is  very  scanty.  Schles- 
inger  believes  it  is  possible  to  dispense  with  the  artificial  anemia  by  the  injection 
of  larger  quantities  of  novocain  solution.  He  punctures  a  congested  vein  with  a  thin 
trocar,  places  the  constricting  bandage,  and  injects.  This  method  does  not  explain, 
however,  the  manner  in  which  the  pressure  of  the  vein  valves  is  overcome.  Jerusalem, 
Mantelli,  Hitzrot,  Goldberg,  and  Petrow  report  successful  results  with  this  method, 
von  Eiselsberg  states  in  the  discussion  of  the  report  of  Jerusalem  that  he  only  used 
the  vein  anesthesia  when  other  anesthetic  methods  were  contra-indicated.  The  author 
holds  this  ingenious  method  of  Bier  to  be  a  valuable  addition  to  our  anesthetic 
methods  in  performing  aseptic  operations  upon  the  extremities  when  the  usual  local 
anesthetic  methods  are  not  possible.  Bier  himself  limits  this  method  of  anesthesia 
to  those  cases  in  which  local  anesthesia  is  not  possible. 

ARTERIAL    ANESTHESIA. 

Alms  and  ^Nlaurel  were  the  first  to  describe  the  anesthetic  effects  following  the 
intra-arterial  introduction  of  cocain  with  consequent  paralysis  of  the  muscles  in  the 
area  supplied  by  the  artery  injected  (see  page  84). 

Goyanes,  a  Spanish  surgeon,  reported  in  1909  the  practical  application  of  arterial 
anesthesia,  and  stated  in  1910  that  he  had  performed  amputations  and  resections 
in  23  cases  with  its  use.  In  20  of  these  cases  complete  anesthesia  was  obtained.  Oppel 
performed  many  operations  upon  the  hand  and  foot  using  the  radial,  dorsalis  pedis, 
femoralis  and  brachialis  as  arteries  of  injection.  The  leg  is  made  anemic  and 
ligated;  below  the  constricting  ligature  the  artery  is  exposed  and  the  anesthetic 
injected  by  means  of  a  fine  needle.  Goyanes  used  for  this  purpose  50  to  100  c.c.  of 
a  \  per  cent,  novocain-suprarenin  solution.     Smaller  doses  were  found  insufficient 


THE  VARIOrs  METHODS  OF  USING  LOCAL  ANESTHETIC  DRUGS  167 

by  Oppel.  (Joyanes  rocoiniiu'iided  this  iiit'thod  particularly  for  the  upper  extremity, 
usiug  lumbar  auesthesia  for  the  lower  extremity. 

Ilotz  has  recently  controlled  the  experiments  made  for  arterial  anesthesia.  He 
reconunends  that  the  artery  be  exposed  under  local  anesthesia,  and  the  leg  made 
anemic  just  as  in  win  anesthesia  and  ligated  above.  A  fine  needle  is  then  passed 
obliquely  into  the  artery  and  a  0.5  to  1  per  cent,  novocain  solution  with  su])rarcnin 
injected.  For  the  brachial  artery  20  to  25  c.c.  are  necessary.  For  the  femoral  artery 
40  c.c.  of  a  0.5  per  cent,  novocain-suprarenin  solution  should  be  used.  One  or  two 
minutes  after  the  injection  complete  anesthesia  occurs  in  the  area  supplied  by  the 
artery.  Following  the  use  of  stronger  novocain  solutions  (3  per  cent.)  severe  pain 
occurs.  After  relieving  the  constricting  bandage  sensation  returns  immediately. 
In  this  manner  10  operations  w^ere  performed  on  the  hand,  forearm,  foot,  and  leg. 
In  three  lean  patients  it  was  found  possible  to  inject  the  novocain  solution  into  the 
femoral  and  brachial  arteries  without  exposing  them.  In  these  cases  the  injection 
was  rapidly  made  and  the  leg  immediately  ligated. 

Injurious  effects  were  never  observed.  This  method,  according  to  Hotz,  does  not 
enter  into  serious  competition  with  inhalation  or  local  anesthesia.  It  is  of  value  in 
tubercular  patients,  in  the  aged  with  bronchitis  and  heart  lesions,  and  other  cases 
which  are  not  suitable  for  general  anesthesia. 

That  the  extremity  must  be  ligated  above  the  anesthetized  area  and  that  sensa- 
tion returns  very  quickly  after  releasing  the  constricting  bandage,  is  a  disadvantage 
that  exists  with  arterial  anesthesia  just  as  with  vein  anesthesia.  Arterial  anesthesia 
possesses  the  added  disadvantage  over  vein  anesthesia  in  that  it  is  much  more  diffi- 
cult to  find  the  artery  than  a  superficial  skin  vein.  This  method  should  scarcely  be 
given  further  consideration  in  anesthesia  of  the  upper  extremity,  as  plexus  anesthesia 
is  a  much  easier  procedure. 

The  abo^•e-named  authorities,  as  well  as  Girgolaw,  claim  that  the  intra-arterial 
introduction  of  an  anesthetic  is  less  toxic  than  that  introduced  intravenously,  but 
this  is  of  no  practical  importance,  as  the  ligating  of  an  extremity  according  to  the 
method  of  Bier  renders  such  danger  impossible.  Experiments  which  the  writer  made 
on  animals  in  1900  also  contradict  any  such  theory  (see  page  90).  The  toxicity  of 
these  methods  depends  upon  the  manner  of  injection.  If  cocain  is  injected  into  a 
previously  ligated  or  clamped  artery  its  toxic  action  is  naturally  much  less  than  if 
this  poison  were  injected  into  a  vein  with  an  uninterrupted  circulation.  If,  however, 
the  cocain  is  injected  into  the  circulation  of  a  vein  previously  ligated  or  clamped, 
as  is  done  in  Bier's  vein  anesthesia,  the  toxic  action  will  naturally  be  much  less  than 
if  injected  directly  into  an  unobstructed  arter>'.  Therefore,  we  can  say  with  equal 
right  that  cocain  injected  intravenously  is  less  toxic  than  when  injected  intra- 
arteriallv. 


CHAPTER   X. 

THE   VALUE,   INDICATIONS,  AND  GENERAL  TECHNIQUE   OF  LOCAL 
ANESTHESIA. 

Local  anesthesia  is  not  of  like  value  in  all  branches  of  surgery.  In  ophthalmology, 
laryngology,  and  rhinology  it  has  been  the  most  important  means  of  anesthesia  for 
some  time  past.  In  urology  it  is  of  much  importance.  In  otology  and  gynecology, 
up  to  the  present  time,  it  has  been  of  minor  importance.  With  the  introduction  of 
suprarenin  the  importance  of  this  method  of  anesthesia  in  dentistry  has  been  record- 
breaking.  j\Iany  dentists  have  stated  that  the  introduction  of  this  agent  has  been 
of  the  same  importance  to  them  as  general  anesthesia  to  the  surgeon.  The  best 
evidence  of  the  importance  of  local  anesthesia  in  dentistry  is  the  space  given  to 
this  subject  in  the  literature  of  the  last  few  years.  The  value  of  local  anesthesia  in 
surgery  was  quite  uncertain  until  the  discovery  of  cocain.  Then  it  rapidly  reached 
its  climax. 

In  the  years  following  its  discovery  many  different  ways  of  using  cocain  were 
tried  in  surgery  with  varying  results,  such  as  infiltration  anesthesia,  conduction  anes- 
thesia, lumbar  anesthesia.  The  beginning  of  the  downfall  of  this  method  began  with 
cocain  poisoning,  but  interest  was  again  renewed  with  improvements  in  technique 
by  Reclus  and  Schleich.  It  seemed  as  though  infiltration  anesthesia  was  to  be  the 
most  important  method  of  anesthesia,  as  conduction  anesthesia,  even  by  the  circum- 
injection  method  of  Hackenbruch,  gave  practical  results  only  on  ligating  an  extremity. 
Infiltration  anesthesia  left  much  to  be  desired,  and  it  would  have  been  soon  forgotten 
again  had  it  not  been  for  the  introduction  of  suprarenin  and  the  supplanting  of 
cocain  by  less  toxic  agents.  These  changes,  together  with  the  improvement  in 
technique  in  other  directions,  helped  to  place  the  method  again  on  a  sound  footing. 
The  new  technique  is  characterized  by  injections  around  the  operative  field,  the  block- 
ing of  individual  nerves,  and,  where  possible,  combining  these  methods  with  infiltra- 
tion of  the  line  of  incision,  as  described  by  Reclus  and  Schleich.  Ligation  is  not 
necessary  at  present  with  conduction  anesthesia,  for  which  reason  this  method  can  be 
used  equally  well  in  other  parts  of  the  body.  Conduction  and  infiltration  anesthesia 
are  by  far  the  most  important  means  of  producing  local  anesthesia.  Anesthesia  of 
superficial  surfaces  still  has  a  limited  field  of  usefulness.  The  most  important  feature 
is  the  possibility  of  injecting  into  the  body  as  much  of  a  solution  as  desired,  pro- 
ducing a  local  anesthesia  of  such  intensity  and  duration  as  has  never  before  been 
known.  This  fact  alone  placed  anesthesia  in  the  foreground  in  surgery  and 
assured  its  further  progress.     Improvements  in  technique  with  the  older  agents  would 


VALUE,   INDICATIONS,   GENERAL   TECHNIQUE  OF   LOCAL   ANESTHESIA     109 

not  \\ii\v  hrougiit  about  this  change.  The  introthiction  of  noxocain  and  suprarmin 
were  just  as  important  for  local  anesthesia  as  the  discovery  of  cocain. 

Up  to  the  present  time  the  field  of  local  anesthesia  was  limited  to  minor  or  so-called 
ambulatory  surgery.  Very  few  surgeons  performed  any  of  the  classical  operations  of 
major  surgery  with  the  aid  of  local  anesthesia;  but  of  late  years,  thanks  to  the 
improved  and  simplified  technique,  this  method  has  gained  many  adherents,  as  sig- 
nified by  communications  from  Roith,  Xast-Kolb,  Bier,  Madelung,  Axhausen,  Hesse, 
and  others.  Statistics  of  various  institutions  demonstrate  the  extent  to  which  it 
is  used,  not  only  in  ambulatory  cases  but  also  in  major  surgery,  as  is  graphically 
shown  in  the  constantly  rising  curve  (see  table). 

Local  anesthesia  possesses  marked  ad^'antages  over  general  and  lumbar  anesthesia. 
It  is  not  associated  with  any  danger  to  life,  and  the  general  condition  of  the  patient 
as  well  as  the  surgical  convalescence  not  disturbed,  as  is  so  often  noted  after 
general  anesthesia.  Ambulatory  cases  require  no  further  attention  and  can  be 
immediately  discharged.  We  have  learned  of  late  how  to  produce  local  anesthesia  of 
sufficient  duration  to  carry  the  patient  in  comfort  over  the  painful  hours  immediately 
following  operation.  The  claim  that  postoperative  pain  is  more  severe  after  local 
than  after  general  anesthesia  has  not  been  verified  by  experience.  There  are,  of 
course,  patients  operated  upon  for  various  conditions  who  complain  of  severe  pain 
no  matter  what  the  nature  of  the  anesthetic.  Local  anesthesia  does  not  increase 
these  pains,  but,  on  the  contrary,  lessens  them  until  the  return  of  sensation.  A  skilled 
anesthetist  is  naturally  unnecessary;  but  it  is  important  that  someone  should  busy 
himself  with  the  patient  during  a  prolonged  operation  (moral  anesthetist) .  A  feature 
of  local  anesthesia  not  to  be  underrated  is  the  bloodless  operative  field  obtained, 
due  to  the  suprarenin,  an  advantage  of  much  value  in  certain  operations. 


Heidelberg  Clinic   (Narath 

Wilms) 

Year. 

No.  of  operations. 

General  Anesthesia. 

Local  Aaesthesia. 

Lumbar. 

1906 
1907 
1908 
1910 
1911 

1917 
1936 
2070 
2303 
2532 

1633    (85.0%) 
1377    (71.0%) 
1460    (70.5%) 
1583    (68.7%) 
1063    (42.0%o) 

218 
426 
559 
632 
1375 

(11-4%) 
(22.0%) 
(27.0%) 
(27.4%) 
(54.2%) 

33 

106 
20 

10 

(1.7%) 
(5.5%) 
(1-0%) 

Hospital  of  Stettin 

(HE.SSE). 

190S 
1909 

1762 
1940 

1364    (77.3%) 
1294    (66.7%) 

Hospital  at  Zwick.\u 

(Br 

199 
413 

.-^.UN). 

(11.3%) 
(21.3%) 

15 

26 

(0.8%) 
(1.3%) 

1908 
1909 
1910 
1911 
1912 

1529 
1542 
1811 
1898 
1866 

1078    (70.3%o) 
995    (64.5%) 

1029    (56.8%) 
987    (52.0%) 
903    (48.0%) 

375 
489 

727 
817 
922 

(24.8%) 
(31.7%) 
(40.1%) 
(43.0%) 
(49.0%) 

4 
5 
3 
9 
5 

(0.2%) 
(0.3%) 
(0.1%) 

Surgical  Clinic  of  the  Charity  Hospital   (Axhausen). 
1600  240    (15.0%) 


170  LOCAL  ANESTHESIA 

It  has  been  charged  that  local  anesthesia  takes  too  much  time.  This  is  certainly 
a  mistake,  as  the  anesthetizing  of  the  operative  field  requires  less  time  than  a  general 
anesthetic.  The  claim  that  local  anesthesia  interferes  with  the  exact  performance 
of  the  operation  will  be  noted  only  in  the  early  attempts  of  the  inexperienced;  as  a 
rule  the  reverse  is  true.  The  operator  using  this  method  must  be  qualified  to  know 
its  technique,  indications,  and  limitations,  in  this  regard  sharing  the  technical 
experience  of  surgery  in  general.  Poor  and  insufficient  local  anesthesia,  of  course, 
will  occur  even  to  the  most  experienced,  just  as  we  have  poor  general  anesthesia. 
The  former  brings  no  ill  effects,  while  the  latter  may  have  serious  consequences. 

Where  possible,  local  anesthesia  should  be  the  method  of  choice  in  operations  not 
requiring  too  large  a  quantity  of  the  anesthetic^ — when  the  field  of  operation  can  be 
rendered  completely  insensitive ;  when  the  operator  knows  the  technique  and  limita- 
tions of  the  method;  and  when  the  psychical  condition  of  the  patient  will  permit  of 
operation  without  the  loss  of  consciousness  produced  by  general  anesthesia. 

Regarding  this  last  requirement  it  might  be  said  that  the  importance  of  psychical 
contra-indications  was  much  overrated  during  the  developmental  period  of  the 
method  by  the  surgeons.  Xow,  it  is  of  minor  concern.  As  soon  as  the  patient  finds 
that  there  really  is  no  pain  during  the  operation  he  quiets  down  at  once,  even 
in  lengthy  and  serious  operations.  The  knowledge  that  local  anesthesia  is  possible 
is  becoming  more  widely  known,  and  excitable  patients  and  well-bred  children,  with 
the  proper  preparation  and  other  minor  expedients,  as  will  be  described  later,  become 
readily  converted  to  this  method  of  operating. 

A  combination  of  local  and  general  anesthesia  may,  for  various  reasons,  become 
necessary,  as,  for  instance,  when  local  anesthesia  is  discovered  to  be  imperfect. 
The  greater  the  practice  and  experience  of  the  operator  the  less  often  is  such  an 
occurrence  noted.  In  some  cases  a  combination  with  general  anesthesia  may  have 
been  decided  upon  beforehand.  A  superficial  ether  or  ethyl  chloride  anesthesia  may 
be  required  just  at  the  beginning  of  the  operation  for  the  purpose  of  quieting  the 
patient  or  causing  a  certain  degree  of  mental  confusion.  There  are  operations  which 
can  be  done  in  large  part  under  local  anesthesia,  while  certain  phases  may  require 
the  first  stage  of  general  anesthesia  for  their  completion.  Lengthy  abdominal  or 
stomach  operations  in  weak  persons  can  be  carried  out  in  this  way  with  much  less 
danger  to  the  patient  than  if  the  entire  operation  had  been  performed  under  general 
anesthesia. 

Kroenig  tells  how  patients  can  be  prepared  for  lumbar  anesthesia  with  the  aid  of 
morphin,  scopolamin,  veronal,  etc.,  which  are  used  successfully  in  local  anesthesia. 
INIost  patients,  of  course,  do  not  require  these  aids,  which  have  certainly  no  place 
in  minor  surgery.  They  are  necessary,  however,  in  excitable  and"  anxious  patients, 
particularly  in  operations  which,  according  to  their  nature,  unusual  length  of  time, 


i 


VALVE,    IXDICATIOXS,    CKNKRAL    TECll NIQI'K   OF    LOCAL   ANESTHESIA      171 

and  their  iin})erati\eness,  re(iiiire  iiiic()iiil'()rtal)le  positions  on  tlic  table,  taxing;-  hotii 
the  eonraiiv  and  patience  of  the  patient;  also  in  operations  which,  as  known  from 
experience,  cannot  he  completed  without  general  anesthesia.  It  is  not  by  mere 
coincidence  that  gynecologists,  almost  without  exception,  advise  the  use  of  nar- 
cotic drugs  in  the  preparation  of  patients,  even  wdien  inhalation  anesthesia  is  not  to 
})e  used.  Narcotic  drugs  in  genital  operations  in  women  are  very  necessary.  On  the 
other  hand,  some  w^omen  require  no  preparation  in  hemorrhoid  operations.  The 
author  confines  himself,  when  possible,  to  the  use  of  morphin  in  doses  of  0.01  to  0.02 
according  to  the  constitution  of  the  patient.  Scopolamin-morphin  sleep  is  very 
A'alnable  in  the  preparation  of  a  patient,  but  we  encounter  difficulties  in  arriving  at 
the  proper  dosage.  The  usual  dose  of  scopolamin  (0.0005)  and  morphin  (0.01)  is 
often  too  small  and  has  the  same  effect  as  morphin  alone,  while  in  elderly  persons  this 
dose  may  be  too  large.  The  graduated  doses  of  these  agents,  as  advised  by  Kroenig, 
can  hardly  be  carried  out  in  hospital  practice  without  decidedly  increasing  the 
personnel. 

The  prevailing  opinion  that  children  are  not  suitable  patients  for  local  anesthesia 
is,  as  Ivredel  states,  no  longer  tenable.  Some  children  are  easily  influenced,  and 
readily  permit  the  injection,  particularly  if  chocolate  or  other  sweets  are  offered. 
We  operate  for  empyema,  also  for  hernise  as  does  Kredel,  in  children  as  young  as 
four  years  of  age,  mostly  under  local  anesthesia.  The  old  methods  of  local  anesthesia 
were  unsuitable  for  children,  and  also  for  anxious  and  sensitive  persons,  on  account 
of  their  uncertainty.  Frequently  during  the  operation  it  became  necessary  to  renew 
the  injection  first  in  one  place  then  in  another,  owing  to  an  insufficient  anesthesia. 
Kredel  suggests  a  most  clever  way  of  preparing  nursing  babies  for  local  anesthesia. 
The  baby  is  first  allowed  to  liecome  hungry,  then,  at  the  beginning  of  the  injection, 
it  is  given  a  bottle,  after  which  it  does  not  concern  itself  with  what  goes  on. 

The  modern  operating-table  is  very  comfortable  for  the  operator,  but  for  the  patient 
operated  upon  under  local  anesthesia  there  is  much  to  be  desired.  When,  therefore, 
a  particular  position,  such  as  a  Trendelenburg  or  reverse  Trendelenburg,  is  not  neces- 
sary, the  patient  should  rest  on  a  mattress  placed  upon  a  smooth  table  and  covered 
with  sterile  rubber  cloth  and  sheets,  and  thus  made  comfortable  for  the  ordeal. 


INSTRUMENTARIUM. 

The  instruments  necessary  for  local  anesthesia,  especially  for  infiltration  and  con- 
duction anesthesia,  consist  of  syringes,  needles,  and  receptacles  for  the  anesthetic 
to  })e  employed.  Syringes  of  2.5,  5  and  10  c.c.  are  necessary,  and  must  stand  boiling. 
They  should  not  be  short  and  thick,  but  rather  long  and  thin,  so  that  the  diameter 


172  LOCAL  ANESTHESIA 

of  the  piston  is  small  and  compact.  The  pressure  of  fluid  in  the  needle  is  considerably 
greater  the  smaller  the  diameter  of  the  piston.  This  is  of  much  importance  in  injecting 
into  dense  tissues.  The  syringe  should  be  well  adapted  to  the  hand  and  should  have 
an  attachment  for  making  counter-pressure,  such  as  a  cross  bar  or  rings ;  or,  what  the 
writer  believes  best,  a  groove  that  will  fit  the  second  and  third  fingers.  The  "Record" 
syringe,  made  in  Germany,  consists  of  a  glass  cylinder  with  metal  piston.  It  does 
not  fulfil  all  the  requirements  mentioned,  as  it  is  too  short  and  thick  and  has  no 
arrangement  for  making  counter-pressure.  Hammer,  in  his  criticism  of  this  syringe, 
claims  it  requires  too  much  attention.  The  piston  must  be  removed  when  boiled, 
and,  in  spite  of  the  best  of  care,  the  glass  cylinders  will  occasionally  break  either 
during  the  boiling  or  cooling.  On  account  of  the  great  cost  consequent  on  breakage, 
Hammer  and  the  writer  have  given  up  the  glass  syringe  for  the  all-metal  one.  j\Ietal 
syringes  are  much  better  than  in  former  years,  and  the  operator  soon  grows  accus- 
tomed to  not  being  able  to  see  the  fluid. 


Fig.  10. — The  Hammer  syringe. 

Hammer  has  constructed  an  all-metal  syringe  in  which  the  solution  to  be  injected 
is  poured  in  from  a  side  opening  in  front  of  the  fully  extended  piston  (Fig.  10).  The 
fault  of  this  syringe  is  that  in  order  to  fill  it  the  needle  which  is  fixed  to  the 
syringe  must  be  withdrawn.  It  is  very  important  that  the  needle  should  remain  in 
the  tissues,  and,  therefore,  most  essential  that  the  syringe  and  needle  should  be 
detachable.  This  feature  far  outweighs  the  slight  trouble  of  occasionally  separating 
the  instrument.     Figs.  11  and  12  show  good  syringes. 

Injections  made  under  the  skin  and  parallel  with  its  surface  are  sometimes  difficult 
to  carry  out  if  the  needle  is  attached  in  the  long  axis  of  the  syringe,  owing  to  the 
conformation  of  the  body.  For  this  reason  Hackenbruch  constructed  a  syringe  with 
the  needle  fixed  at  right  angles.  This  arrangement,  however,  has  the  great  drawback 
that  it  is  difficult  to  feel  the  point  of  the  needle,  the  location  of  which  constitutes 
really  the  whole  secret  of  local  anesthesia.    This  diflficulty  is  overcome  bj'  the  needle- 


VALVE,   IXDICATIONS,   GEXERAL   TECIIMQUE  OF   LOCAL   ANESTHESIA     173 

holder  presrntly  to  be  (les(Tii)e(l,  in  wliieli  the  iiee(Ue  is  attaehed  at  riii;ht  au.des  to  a 
cone-shaped  end. 

The  needles  mnst  be  as  fine  as  their  stability  will  permit,  so  that  an  injnry  such 
as  the  unintentional  pricking  of  a  bloodvessel  will  not  be  of  serious  consequence. 
We  have  always  used  needles  made  of  steel.  Platino-iridium  needles  are  too 
costly,  while  nickel  needles  become  dulled  too  quickly.     The  needle-points  should 


.,-g.=^ 


A 


O     J-:^^ 


Fig.   11. — -Shields'  syringe. 

ha^•e  a  short  bevel  and,  of  course,  must  fit  the  syringe  perfectly.  This  should  be 
tested  In-  filling  the  syringe  with  water  and  attempting  to  inject  with  the  point  of 
the  needle  in  a  cork.    There  must  not  be  any  leakage  between  needle  and  syringe. 

The  needles  which  the  author  uses  are  shown  actual  size  (Fig.  13).  The  fine  short 
needle  Xo.  1  is  used  only  for  the  formation  of  wheals  at  the  various  points  of  injection, 
the  longer  needles  being  used  for  the  completion  of  the  injection.  Half-curved  angular 
needles  are  entirely  unnecessary.  The  needleholder  as  shown  (Fig.  14)  is  indis- 
pensable as  a  guide  for  the  long  needles  when  used  in  the  trifacial,  lumbar,  and  sacral 


injections.  The  needle  is  firmly  held  in  the  holder  by  means  of  two  jaws  operated 
by  a  screw.  The  slip-joint  for  attaching  the  syringe  is  made  at  an  angle,  which  is  an 
advantage  over  syringes  with  angular  ends  or  angular  attachments  such  as  have  been 
described  by  Hackenbruch.     It  is  at  times  necessary  to  know  beforehand  the  length 

1  The  syringe  (as  shown  in  Fig.  11)  is  patterned  after  the  Hammer  syringe.  It  differs  in  having  a  slip 
joint  which  facilitates  changing  of  the  needle.  The  opening  at  the  back  part  of  the  syringe  is  surrounded 
by  a  funnel-shaped  collar,  which  renders  the  filling  of  the  syringe  easier.  The  syringe  is  made  in  two  sizes 
of  .5  and  10  c.c.  capacity. — Editor. 


174 


LOCAL  ANESTHESIA 


of  the  needle  to  be  used  in  the  injection  of  certain  parts  of  the  body,  for  example, 
injections  into  the  foramen  rotundum  and  ovale.  For  this  purpose  a  piece  of  cork  is 
slipped  over  the  needle  and  placed  at  a  point  previously  measured  on  the  needle  to  act 


Thickness    .       0.5        0.5  0.6  0.7  0.7  0.7  0.9  mm 

Length  .      .         25  30  35  60  SO  90  125  mm. 

Fig.   13. — Diagram  showing  needles  in  natural  size. 


J 


VALUE,   INDICATIONS,   GENERAL    TECHNIQUE   OF    LOCAL   ANESTHESIA      17.") 

as  a  iiiiide.  'V\\v  use  of  special  lU'cdlrs  with  a  iiradiiated  scale  marked  111)011  them  is 
unnecessarily  costl\'  and  at  times  iiicoinenieiit.  A  de\iatioii  from  the  usual  form  of 
needle  has  been  de\ised  by  Schleich  and  consists  of  a  cone-shaped  end  which  is  pressed 


Fig.   14. — Xeedleholder,  showing  cork  i)laeecl  c 


at  a  definite  measured  point. 


into  the  end  of  the  Schleich  syringe  (Fig.  15).  This  makes  a  very  stable  and  tight 
connection,  but  cannot,  however,  be  readily  separated.  The  needles  belonging  to  the 
syringe  outfit  of  Schleich  are  too  short.  Complications,  unpleasant  for  both  patient  and 
operator,  sometimes  result  from  breaking  oflF  and  losing 
a  needle  in  the  tissues,  and  lawsuits  often  follow  acci- 
dents of  this  kind.  This  mishap  can  occur  with  the 
most  skilled,  as  it  is  impossible  at  times  to  prevent  the 
needle  from  breaking  where  it  joins  the  hub.  This  of  course 
applies  to  needles  which  have  not  been  damaged  by  rust. 
For  this  reason  it  should  be  the  rule  that  a  needle  must 
never  be  pushed  into  the  tissues  as  far  as  the  hub;  it  will 
then  be  impossible  to  lose  a  broken  needle  in  the  tissues. 
Very  long  needles  should  be  used  in  making  injections 
into  parts  of  the  body  difficult  of  access,  as,  for  instance, 
injections  carried  out  in  the  hidden  recesses  of  the  mouth, 
on  the  inner  surface  of  the  lower  jaw,  or  the  tuber  maxilla? 
in  dental  operations.  In  operations  at  this  depth,  the 
needle  should  be  of  such  length  that  it  will  not  be 
necessary  to  have  the  syringe  enter  the  mouth. 

For  the  preparation  of  the  various  solutions,  glass  graduates  of  from  5  to  20  c.c. 
capacity,  and  porcelain  measures  of  150  to  250  c.c.  capacity  are  necessary.  The 
solutions  can  be  used  directly  from  these  vessels.  In  the  preparation  of  small  quan- 
tities of  the  solutions  watch  glasses,  as  used  for  microscopic  purposes,  are  ^■ery 
satisfactory. 


17G 


LOCAL  ANESTHESIA 


Syringes  and  needles  are  sterilized  by  boiling  in  a  soda  solution.  This  must 
be  thoroughly  removed  by  subsequent  washing  in  salt  solution,  as  both  novocain 
and  suprarenin  deteriorate  in  the  presence  of  soda.  After  use,  syringes  and  needles 
should  be  cleansed  in  alcohol  and  dried.    Vessels  and  graduates  should  be  sterilized 


Fig.   16. — Table  for  local  anesthetic  apparatus. 

by  boiling,  or  may  be  kept  in  a  3  per  cent,  carbolic  acid  solution  until  used  again. 
They  should  then  be  thoroughly  washed  in  salt  solution.  Fig.  16  shows  a  well-arranged 
portable  table  for  the  equipment  necessary  in  local  anesthesia.  This  table  provides 
for  instrument  trays  in  which  syringes  and  needles  can  be  boiled,  an  enameled  iron 
basin  for  salt  solution  used  in  washing  the  soda  from  instruments,  a  similar  basin 
for  a  carbolic  solution  in  which  graduates  and  other  vessels  are  kept,  a  liter  flask 
for  salt  solution  and  a  spirit  lamp. 

The  apparatus  as  shown  (Fig.  17)  consists  of  a  glass-top  table  having  suspended 


VALUE,    INDICATIOXS,    CEXERAL    TECHXIQCK   OF   LOCAL    ANESTHESIA     177 

from  ail  upriu'ht  a  2.")()  c.c*.  u'lass  graduate  with  a  tajxTinu-  ulass  ciHl-i)i(>ce  connected 
to  the  gracUiate  with  rubber  tubing  closed  by  a  i)inch-cock.  An  alcohol  lamp  with 
a  small  porcelain  vessel  for  dissolving  and  boiling  the  tablets  and  one  or  two  other 
glass  graduates  complete  the  outfit.  The  advantage  of  this  apparatus  consists  in 
dispensing  with  one  assistant,  of  rapidly  and  accurately  filling  the  syringe,  and 
knowing  the  exact  quantity  of  the  anesthetic  solution  which  has  been  injected. 


Fig.  17. — Shields'  outfit  for  local  anesthesia. 


SOLUTIONS    USED    IN    ANESTHESIA. 


The  solutions  used  for  anesthesia  should  be  isotonic 
62),  for  which  purpose  a  strong  In-potonic  physiological 
12 


s  near  as  possible  (see  page 
salt  solution  is  used.    To  be 


178  LOCAL  ANESTHESIA 

exact,  the  strength  of  the  salt  sokition  should  vary  with  the  concentration  of  the  anes- 
thetic, but  this  is  neither  practical  nor  necessary.  A  5.4  per  cent,  solution  of  novocain 
constitutes  a  physiological  solution,  for  which  reason  a  4  per  cent,  novocain  solution 
is  best  prepared  by  dissolving  in  water  instead  of  salt  solution.  Salt  must  therefore 
never  be  added  to  hypertonic  solutions.  Cocain,  at  least  in  surgery,  has  become 
obsolete.  For  infiltration  and  conduction  anesthesia  novocain  combined  with  supra- 
renin  is  the  combination  of  drugs  most  recommended.  Novocain  can  be  ster- 
ilized by  boiling,  after  which  it  will  keep  indefinitely.  Suprarenin,  on  the  contrary, 
is  a  very  delicate  drug,  for  wdiich  reason  certain  precautions  are  necessary  in  its 
use.  The  suprarenin  of  commerce  is  known  by  various  trade  names,  viz.:  adrenalin, 
suprarenin,  paranephrin,  tonogen,  etc.  In  Germany  the  American  product  adrenalin 
and  the  suprarenin  of  German  manufacture  are  most  commonly  used.  The  latter  is 
synthetically  prepared  and  is  placed  on  the  market  in  a  solution  of  1  to  1000,  with  the 
addition  of  hydrochloric  acid  and  an  antiseptic  such  as  acetone,  chloroform,  thymol^ 
etc.,  to  insure  its  stability.  In  this  form  the  solution  can  be  sterilized  by  boiling,  and, 
if  kept  in  alkaline-free  glass,  remains  unchanged  for  a  considerable  time.  Compressed 
tablets  containing  1  mg.  of  suprarenin  can  be  obtained,  and  tablets  are  likewise  on 
the  maiket  containing  the  anesthetic  drug  with  the  requisite  amount  of  suprarenin. 
In  dental  practice  glass  ampoules  are  preferred  by  many,  each  ampoule  containing  a 
small  quantity  of  the  anesthetic  and  suprarenal  substances  in  solution.  Preparations 
dispensed  in  this  way  have  little  to  recommend  them.  They  are  costly  and  not  fitted 
for  physicians'  use.  The  writer  personally  prefers  the  tablet  as  used  in  the  dispensing 
of  all  alkaloids  employed  in  medicine ;  this  applies  to  unstable  drugs  particularly,  such 
as  suprarenin.  Suprarenin  is  not  stable  in  solution,  while  in  tablet  form  it  remains 
unchanged  indefinitely.  Diluted  solutions  of  suprarenin  become  red  quickly  when 
exposed  to  the  air  without,  however,  losing  any  of  their  effectiveness.  After  longer 
exposure  these  solutions  turn  brown  and  then  are  unfit  for  use.  Lieble  states,  and 
with  perfect  right,  that  solutions  made  from  the  solid  substance  of  suprarenin,  par- 
ticularly the  tablets,  are  the  most  reliable.  A  chemist  engaged  in  the  manufacture 
of  suprarenin  writes:  "The  stability  of  suprarenin  solutions  is  dependent  upon 
many  contingencies  which  cannot  be  avoided  even  with  utmost  care." 

The  sterility  of  the  manufactured  tablet  cannot  be  depended  upon  even  though  the 
manufacturer  claims  the  tablets  are  sterile.  Hoffmann  and  Kutscher  found  bacteria 
in  a  number  of  tablets  which  they  examined,  and  it  is  not  a  remote  possibility  that 
pathogenic  bacteria  could  also  be  found.  Inasmuch  as  the  dry  substance  cannot 
be  sterilized,  it  is  necessary  to  sterilize  solutions  made  from  these  tablets  before  use. 
Solutions  prepared  from  synthetic  suprarenin  can  be  sterilized  by  boiling  without 
injury. 

Anesthetic  solutions  can   be  prepared  in  various  ways.     1.   The  writer  has  had 


VALVE,   IXDICATIONS,   GENERAL    TECIIXIQVE   OF   LOCAL   ANESTHESIA     179 

prepared  by  IIoeclistcr-Farbwerke'  tablets  of  n()V()eaiii-suj)rareiiin,  so-called  tablet  A 
containing  0.125  novocain  hydrochloride  and  ().()()()125  of  synthetic  suprarenin  in  the 
form  of  a  water-soluble  salt,  the  tartrate  being  the  one  used  at  present.  1-2-4  of 
these  tablets  dissolved  in  25  c.c.  of  physiological  salt  solution  produce  0.5  to  1  to  2 
per  cent,  solutions.  The  tablets  necessary  for  an  operation  are  placed  in  a  small 
porcelain  dish  or  sterile  test-tube,  covered  with  sufficient  physiological  salt  solution 
and  sterilized  by  boiling.  This  solution  is  then  placed  in  a  porcelain  vessel  and  diluted 
with  salt  solution  as  desired,  and  used  directly  from  this  vessel. 

2.  Approximately  1  mg.  of  suprarenin  is  added  to  200  c.c.  of  a  0.5  per  cent,  solution, 
100  c.c.  of  a  1  per  cent,  solution,  50  c.c.  of  a  2  per  cent,  solution  and  25  c.c.  of  a 
4  per  cent,  solution.  In  institutions  where  large  quantities  of  the  anesthetic  are 
required  daily,  the  following  procedure  will  be  of  value.  A  4  per  cent,  novocain  solu- 
tion is  sterilized  and  kept  ready  for  use  in  cotton  stoppered  glass  flasks.  A  tablet 
of  1  mg.  suprarenin  is  dissolved  as  before  mentioned  and  then  boiled  and  added  to 
25  c.c.  of  the  4  per  cent,  novocain  solution.  This  novocain  suprarenin  solution  is 
now  diluted  with  salt  solution  as  desired. 

3.  At  times  it  becomes  necessary  to  prepare  these  solutions  from  a  1  to  1000 
solution  of  suprarenin,  for  which  purpose  either  the  commercial  preparation  is  used, 
which  must  be  sterilized,  or  the  solution  is  made  from  the  suprarenin  tablets  and 
placed  in  a  drop  bottle.  In  preparing  this  solution  10  suprarenin  tablets,  each 
containing  1  mg.,  are  added  to  10  c.c.  of  distilled  water  to  which  3  drops  of  dilute 
hydrochloric  acid  have  been  added;  this  is  then  boiled.  Before  using  the  drop  bottle 
it  is  very  necessary  to  know  the  number  of  drops  per  c.c,  as  without  this  precaution 
the  strength  of  suprarenin  would  be  most  unreliable,  as  the  number  of  drops  per  c.c. 
varies  between  10  and  20,  depending  upon  the  bottle.  When  the  correct  number  of 
drops  is  known  this  amount  of  the  liquid  is  added  to  the  requisite  quantity  of  novo- 
cain solution.  It  is  best  in  preparing  these  solutions  to  have  a  graphic  formula  to 
work  by  as  the  following: 

16  gtt.  suprarenin  solution  1  to  1000  =  1  c.c.  =  1  nig.  suprarenin. 
to  be  added  to 
200  c.c.  0.5%  1 
100  c.c.  1.0% 
50  c.c.  2.0% 
25  c.c.  4.0% 


Novocain  .solution. 


From  this  diagram  it  becomes  at  once  apparent  how  many  drops  of  the  suprarenin 
solution  are  necessary  for  larger  or  smaller  quantities  of  the  novocain  solution. 
The  use  of  tablets  in  the  preparation  of  these  solutions  is  the  simplest  and  most 

^  Hoechster-Farbwerke  prepares  novocain  and  suprarenin  in  ampoule  form,  insuring  sterility. 


180  LOCAL  ANESTHESIA 

trustworthy  procedure,  and,  outside  of  hospitals,  the  only  method  to  be  recommended. 
It  would  certainly  not  be  justifiable  to  have  alkaloid  solutions  prepared  by  the  drug- 
gist and  then  kept  on  the  shelf  until  ready  for  use.  The  1  per  cent,  solution  of 
novocain-suprarenin  is  suitable  for  nearly  all  purposes  and  should  be  recommended 
for  general  use,  but  for  major  operations  it  will  often  be  advantageous  to  have  solu- 
tions of  different  strengths.  The  0.5  per  cent,  novocain-suprarenin  solution  is  the 
one  the  author  uses  most  frequently,  whereas  the  1  to  2  and  4  per  cent,  solutions  are 
reserved  for  anesthesia  of  the  larger  nerve  trunks,  in  cases  where  a  rapid  and  periph- 
eral anesthesia  or  a  more  intense  suprarenin  anemia  is  desired.  Since  Laewen  has 
shown  that  the  4  per  cent,  novocain-suprarenin  solution  is  harmless,  even  in  large 
quantities,  the  author  has  been  using  this  solution,  and  will  describe  it  later  in  detail. 

The  dosage  of  novocain  and  suprarenin  has  already  been  discussed  on  pages  124 
and  144.  More  than  1.25  novocain  (250  c.c.  of  0.5  per  cent,  solution,  125  c.c.  of  1 
per  cent,  solution)  can  be  injected  without  toxic  effect.  In  using  the  2  to  4  per  cent, 
solutions  it  is  best  not  to  exceed  0.8  of  novocain,  and  if  injections  are  made  into  dense 
vascular  tissues  like  the  gums,  the  fractional  quantity  of  this  dose  should  not  be 
exceeded,  although  additional  quantities  of  the  0.5  and  1  per  cent,  solution  can  be 
used  without  danger.  In  using  strong  solutions,  always  observe  Laewen's  rule  to 
inject  sloivly. 

As  a  rule  the  dosage  of  novocain  need  not  be  given  much  thought,  provided  no 
attempt  is  made  to  anesthetize  too  large  an  operative  field.  The  progress  of  local 
anesthesia  is  based  upon  this  fact.  The  reason  why  the  dosage  of  suprarenin  in  local 
anesthesia  is  without  consequence,  and  why  the  concentration  of  suprarenin  in  anes- 
thetic solutions  should  not  be  exceeded,  has  already  been  discussed  on  page  145. 

Solutions  of  alypin  for  anesthesia  of  mucous  membranes  can  be  prepared  in  the 
proper  strength  and  necessary  quantity  from  tablets  containing  alypin  0.2  and  supra- 
renin 0.00033. 


GENERAL    TECHNIQUE    OF    INFILTRATION    AND    CONDUCTION 

ANESTHESIA. 

Infiltration  anesthesia  and  conduction  anesthesia  are  theoretically  entirely  different 
procedures.  In  practice,  however,  they  are  not  separated  and  must  be  considered 
together.  Their  development  and  relation  to  one  another  has  already  been  described 
in  Chapter  IX,  and  in  this  chapter  the  influence  of  modern  anesthetic  agents  on  the 
technique  of  the  methods  is  given  in  detail. 

We  no  longer  attempt  to  systematically  infiltrate  the  layers  of  the  tissues  in  the 
proposed  line  of  incision,  as  described  by  Reclus  and  Schleich.     AYe  anesthetize  by 


VALUE,   INDICATIONS,   GENERAL   TECHNIQUE  OF  LOCAL  ANESTHESIA     LSI 

infiltration  certain  layers  of  the  tissues  alone,  or  in  connection  with  the  hreakin*;- 
of  eoiiduetion  of  certain  ner\e  trunks  before  their  distribution  in  the  operative 
field,  it  should  he  honu'  in  mind  that  injections  are  not  permissible  in  diseased 
tissues.  In  practice  we  sel(h)m  use  the  direct  infiltration  of  the  tissues,  that  is,  infil- 
tration anesthesia,  but  usually  combine  infiltration  of  the  tissues  with  conduction 
anesthesia.  It  can  be  readily  seen  that  a  particular  method  of  anesthesia  is  necessary 
for  every  operative  field  or  part  of  the  body.  P'or  the  practical  application  of  local 
anesthesia  little  is  gained  from  the  knowledge  of  the  general  technique  of  injection, 
but  it  is  necessary  to  have  a  comprehensive  knowledge  of  the  sensory  innervation 
of  the  operative  field.  For  these  reasons  it  is  impossible  to  describe  briefly  the  tech- 
ni(iue  of  infiltration  and  conduction  anesthesia.  In  the  surgical  text-books  of  the 
future  it  will  not  be  sufficient  to  place  the  subject  of  local  anesthesia  next  to  that  of 
general  anesthesia  and  dispose  of  it  in  a  short  resume,  with  the  mere  mentioning  of 
such  historic  names  as  Reclus,  Schleich,  Oberst,  and  Hackenbruch.  The  subject 
must  be  taken  up  fully  and  the  technique  for  each  operation  given  in  detail. 

Inasmuch  as  the  injected  agent  does  not  immediately  produce  its  maximum  effect, 
either  as  to  intensity  or  extent  of  anesthesia,  except  w^hen  the  agent  is  injected  ender- 
matically,  it  is  necessary  to  circumscribe  the  operative  field  by  the  requisite  injec- 
tions before  beginning  the  operation.  The  injection  of  the  deeper  layers  of  the  tissues 
should  be  made  first,  as  the  primary  injection  into  the  subcutaneous  connective  tissue 
would  render  the  technique  of  the  deeper  injections  more  difficult.  At  the  present 
time  it  is  usually  unnecessary  to  repeat  injections  during  the  operation,  a  distinct 
advantage  in  that  valuable  time  is  lost  in  waiting  for  the  anesthetic  to  become 
ef}'ecti\'e  when  repetition  is  necessary. 

Anesthesia  by  means  of  injection,  as  carried  out  by  Reclus  and  Schleich,  was  an 
integral  part  of  the  operation.  Today  it  is  independent  of  the  operation,  in  fact  precedes 
it,  and  need  not  be  performed  by  the  operator  or  in  the  operating-room.  Before 
beginning  the  injections,  the  skin  of  the  operative  field  should  be  sterilized  with 
benzine  or  iodin-benzine,  or  the  points  of  entrance  of  the  needle  can  merely  be 
touched  with  the  tincture  of  iodin.  After  completing  the  injection,  the  preparation 
of  the  operative  field  is  undertaken,  such  as  the  disinfection  of  the  skin,  surrounding 
the  operative  field  with  sterile  towels,  and  locating  the  assistants.  During  this 
preparation  anesthesia  has  attained  its  maximum  effect. 

The  hand  must  be  trained  in  the  skilful  manipulation  of  the  syringe,  which,  as 
shown  in  Fig.  18,  is  held  by  the  thumb,  index,  and  middle  fingers  of  the  right  hand. 
The  wrist  should  be  free,  and  all  lateral  pressure  should  be  avoided  to  prevent  the 
breaking  of  the  needle,  wdiich  must  never  disappear  completely  from  view  in  the  tissues, 
as  already  mentioned  on  page  175. 

For  the  first  punctures  of  the  skin  fine  and  short  needles  should  be  used  (So.  1, 


182 


LOCAL  ANESTHESIA 


Fig.  13).     It  is  impractical  and  unnecessary  to  use  ethyl  chloride  on  the  skin  for  the        j 
first  needle  punctures,  as  the  skin  is  rendered  hard  and  the  insertion  of  the  needle        ] 


Fig.   18. — Manner  of  holding  sj-ringe. 


Fig.   19. — Formation  of  a  skin 


difficult;  likewise  the  pain  consec{uent  upon  freezing  the  skin  is  more  scAcre  than  the 
pricking  of  a  fine  sharp  needle.  The  injections  are  carried  out  from  several  points, 
which  are  later  used  for  injecting  with  longer  and  thicker  needles.     It  is  therefore 


VAIAh\    IXDICATIOXS,   GENERAL    TECHNIQUE   OF   LOCAL   ANESTHESIA     183 


nceossary  to  select  ])()iiits  for  iujeetioii  and  make  them  insensitive  by  the  ender- 
matic  infiltration  or  the  formation  of  a  wheal,  as  described  by  Reclus  and  Schleich, 
the  wheal  formation  at  the  same  time  renders  the  points  visible  to  the  eye.  Points 
for  injection  should  never  be  made  upon  sensitive  parts  as  like  the  flexor  surface 
of  the  finger. 

Kndermatic  infiltration  is  performed  in  the  following  way:  The  needle  is  inserted 
into  the  corium  parallel  to  the  skin  surface  with  the  bevel  upward,  avoiding  the  sub- 
cutaneous connective  tissue,  until  the  opening  of  the 
needle  has  entirely  disappeared  in  the  tissues,  A 
small  amount  of  the  0.5  per  cent,  novocain-supra- 
renin  solution  is  injected,  thus  producing  a  raised 
white  area  or  wheal  which  instantly  becomes  anes- 
thetic and  at  the  same  time  marks  the  first  point  of 
injection  (Fig.  19).  The  other  points  of  injection  are 
made  in  like  manner.  When  the  skin  is  \ev\  thin  and 
mo^•able,  raise  a  fold  of  skin  between  the  thumb  and 
index  finger  and  make  the  injection  for  the  wheal  as 
})efore  mentioned.  In  certain  portions  of  the  body  like 
the  scalp,  palm  of  the  hand,  the  soles  of  the  feet, 
the  endermatic  injection  requires  considerable  pres- 
sure, for  which  reason  it  is  very  essential  to  select 
a  small  syringe  with  a  piston  of  short  diameter  for 
the  formation  of  wheals.  Schleich  and  Reclus  began 
e^•ery  operation  with  endermatic  infiltration. 

After  the  formation  of  the  first  wheal,  the  needle 
may  be  inserted,  if  desired,  into  the  anesthetic  edge 
of  each  successive  wheal;  in  this  manner  a  small 
anesthetic  line  of  any  desired  form  and  length  can  be 
outlined  in  the  skin  (Fig.  20).  In  case  the  skin  is 
normal,  there  is  no  objection  to  this  method  of  anes- 
thesia except  that  it  is  unnecessary,  as  the  skin  will 
become  anesthetic  without  endermatic  infiltration, 
use  the  infiltration  of  the  skin  for  the  purpose  of  marking  and 
place  of  puncture  of  the  needle. 

For  the  purpose  of  making  a  straight  incision  through  the  skin  and  subcutaneous 
tissue  proceed  as  follows:  The  upper  end  of  the  incision  where  the  needle  puncture 
is  to  be  made  is  marked  by  a  wheal,  k  syringe  containing  5  c.c.  of  0.5  per  cent,  novo- 
cain solution,  is  attached  to  a  long  needle;  this  needle  is  then  passed  through  the 
previously  formed  wheal  into  the  subcutaneous  connective  tissue  (Fig.  21),  where 


Fig.  20. — Formation  of  a  series  of 
wheals,  according  to  Schleich. 


For  these 


reasons    we   only 
anesthetizing  the 


184  LOCAL  ANESTHESIA 

under  the  guidance  of  the  fingers  of  the  left  hand  the  needle  is  pushed  to  the  lowest 
point  of  incision  parallel  to  the  skin  surface.  Pressure  upon  the  skin,  so  that  its  under 
surface  is  likely  to  be  abraded,  should  be  avoided  as  it  occasions  considerable  pain. 
During  the  insertion  and  withdrawal  of  the  needle  constant  even  pressure  should 
be  made  upon  the  piston,  so  that  a  narrow  line  of  subcutaneous  connective  tissue 
is  infiltrated.  As  to  the  necessary  quantity  of  solution  for  injection,  it  is  approxi- 
mately correct  to  say  that  for  every  c.c.  of  the  proposed  line  of  incision  1  c.c.  of  the 
solution  be  injected ;  with  a  1  per  cent,  solution  a  correspondingly  smaller  quantity  is 
used.  Immediately  after  the  injection  the  skin  of  the  area  so  treated  is  raised  above 
the  surface  of  the  surrounding  skin  in  the  form  of  a  low,  narrow  wall,  which  disappears 
in  a  very  short  time.  The  elevated  line  is  then  replaced  by  a  white  stripe  in  conse- 
quence of  the  rapid  action  of  the  suprarenin.  In  a  few  minutes  this  strip  of  skin 
becomes  anesthetic,  the  injected  solution  having  not  only  produced  an  infiltration 
anesthesia  but  at  the  same  time  a  conduction  anesthesia  of  the  overlying  skin,  and 


^^-  -'    — ^_-  = =--.-::^ 


Fig.  21.- — Injection  of  the  subcutaneous  connective  tissue  from  two  points. 

the  nerve  supply  to  the  skin  has  been  interrupted.  This  is  the  simplest  form  of  con- 
duction anesthesia.  In  case  one  point  of  puncture  or  the  length  of  the  needle  is 
insufficient  for  infiltration  of  the  proposed  line  of  incision,  injection  from  two  wdieals 
can  be  made  corresponding  to  the  ends  of  the  incision  (Fig.  21).  At  times  it  may  be 
more  desirable  to  make  the  wheal  in  the  centre  of  the  proposed  line  of  incision  and 
inject  from  both  directions.  In  irregular  or  angular  lines  of  incision  the  injection 
can  be  carried  out  from  the  apex  of  the  angle  (Fig.  22,  B)  or  from  two  points  of  injec- 
tion (Fig.  22,  A).  The  injection  of  the  curved  surfaces  of  the  bodj^  by  straight 
introduction  of  the  needle  from  one  point  of  injection  naturally  has  its  limitations, 
for  instance,  in  the  circular  injection  of  the  forearm.  For  this  purpose  four  equi- 
distant points  for  injection  are  selected  from  which  the  circular  injection  is  carried 
out  (Fig.  23).  In  the  infiltrated  area  just  described  not  only  the  subcutaneous 
tissue  and  overlying  skin  become  anesthetized,  but  likewise  the  entire  area  innervated 
by  the  cutaneous  nerves  passing  through  the  infiltrated  area. 


VALUE,   INDICATIONS,   GENERAL    TECHNIQCE  OF   LOCAL   ANESTHESIA     185 

If  the  subcutaneous  connoctivo  tissue  is  systeinaticall>-  infiltrated  in  all  directions 
from  one,  two,  or  more  wheals,  usiui;-  a  lony-  needle,  and  injeetini^  a  ().")  per  cent. 


Fig.  22. — Subcutaneous  injections  made  at  an  angle. 


Fig.  23. — Schematic  cross-section  of  the  forearm.     Infiltration  of  the  subcutaneous  connective  tissue 
from  four  points. 


Fig.  24.— Superficial  infiltr 


novocain-suprarenin   solution   during   the    insertion    and    withdrawal    (Fig.    24),  an 
anesthetic  area  of  any  desired  size  can  be  produced.      In   this  manner  extensive 


186 


LOCAL  ANESTHESIA 


diseased  areas  of  the  skin  can  be  excised  and  in  like  manner  this  method  can  be  used 
for  the  cutting  of  Thiersch  grafts.  Subcutaneous  infiltration  of  the  tumor  base  is 
sufficient  for  the  excision  of  pendulous  skin  tumors  (Fig.  25).  The  tumor  itself  should 
under  no  circumstances  be  infiltrated ;  it  will  then  not  become  enlarged  and  resemble 
a  cucumber,  as  has  been  stated  by  Schleich. 


Fig.  25. — Infiltration  beneath  the  pedicle  of  a  skin  tumor. 


Fig.  26. — Hackenl^ruch's  rhombus. 


What  has  been  said  regarding  the  anesthesia  of  the  skin  and  subcutaneous  con- 
nective tissue  applies  to  the  mucous  membranes,  except  in  the  formation  of  wheals. 
The  injections,  therefore,  should  be  confined  to  the  submucosa,  which  will  necessarily 


VALUE,    INDICATIOXS,   GENERAL    TECHNIQUE   OF   LOCAL   ANESTflESLA      187 

ronder  the  oNtTlying  mucous  iiicnil)r;uu'  insensitive.  In  many  jiarts  of  the  ])ody — 
tor  instance,  the  scalp — the  sensory  nerve  trunks  of  the  skin  and  fascite  lie  in  the 
subcutaneous  connective  tissue,  for  which  reason  large  contiguous  parts  of  the  surface 
of  the  body  ha\e  no  direct  nerve  connection  with  the  subfascial  tissue.  For  this 
reason  it  is  not  always  necessary  to  anesthetize  the  skin  and  subcutaneous  connective 
tissue  of  the  operative  field,  it  being  frequently  sufficient  to  circumscribe  the  operative 
field  b>-  subcutaneous  injections.  Hackenbruch  utilized  these  facts  in  his  circular 
analgesia  (Fig.  26).  Wheals  are  made  at  points  1  and  2.  From  these  points  the 
sulx-utaneous  connective  tissue  is  infiltrated  in  the  direction  1  to  3,  1  to  4,  2  to  3, 
2  to  4,  thus  surrounding  the  entire  field  of  operation  by  a  subcutaneous  wall  of  anes- 
thesia in  the  form  of  an  elongated  rhombus,  termed  Hackenbruch's  rhombus.  The 
longest  diagonal  of  the  rhombus  lies  in  the  direction  of  the  proposed  line  of  incision. 
Wheals  can  also  be  made  at  points  3  and  4  if  more  convenient,  and  the  form  of  the 
encircling  wall  of  the  operative  field  may  be  square,  circular,  or  any  other  desired 
form  that  the  operation  may  require.  The  number  and  position  of  the  points  of 
injection  are  determined  by  the  form  and  size  of  the  operation  (Fig.  27). 


■The  subcutaupous  circuiuiiijectiou  of  an  operative  field  from  six  points. 


In  certain  parts  of  the  body  all  of  the  sensory  nerves  supph'ing  not  only  large  areas 
of  skin  but  likewise  the  deeper  structures  are  located  in  the  subcutaneous  tissues. 
As  an  example  we  might  mention  the  sensory  nerves,  supplying  the  skin,  periosteum, 
and  bones  of  the  skull,  which  in  the  neighborhood  of  the  base,  particularly  the  fore- 
head, are  found  in  the  subcutaneous  connective  tissue.  A  simple  circular  subcutaneous 
injection,  as  shown  in  Fig.  27,  can  be  used  in  outlining  such  operative  fields  of  any 
desired  size  and  will  produce  complete  anesthesia  of  all  structures,  including  the 
bone.  It  may  then  be  said  that  the  Hackenbruch  circuminjection  should  be  con- 
sidered the  normal  procedure  in  anesthesia  of  the  skull.    Hackenbruch  has  rightly 


188 


LOCAL  ANESTHESIA 


stated  that  anesthesia  of  a  finger,  as  described  by  Oberst,  depends  upon  this  same 
principle,  as  the  subcutaneous  connective  tissue  of  the  finger  base  contains  the 
sensory  nerves.  If,  therefore,  the  subcutaneous  tissues  of  the  finger  base  are  circularly 
injected  this  entire  member  will  become  anesthetic. 

It  is  only  in  such  parts  of  the  body  having  the  type  of  innervation  as  already 
described  that  the  subcutaneous  injection  alone  produces  a  useful  anesthesia.  Anes- 
thesia will  not  be  complete  in  operative  fields  circumscribed  by  anesthetic  injections 
if  they  receive  their  innervation  from  below\  For  example,  if  an  operative  field  in  the 
region  of  the  chin  is  injected,  having  the  exit  of  the  mental  nerve  in  its  centre,  anes- 
thesia will  not  occur.    One  of  the  most  elementary  procedures  for  the  induction  of 


Fig.  28. — Infiltration  of  the  needle  tract  used  in  aspirating  the  body  cavities. 


local  anesthesia  consists  in  the  sytematic  infiltration  of  the  different  layers  of  the 
tissues.  The  simplest  form  of  this  mode  of  anesthesia  has  been  described  by  Schleich 
in  connection  with  anesthesia  for  aspirating  various  cavities  of  the  body  (Fig.  28). 
The  point  of  injection  is  marked  by  a  wdieal ;  a  needle  of  proper  length  is  then  inserted 
as  far  as  the  subpleural  or  subperitoneal  connective  tissue,  injection  of  the  anesthetic 
agent  being  continuous  during  the  insertion  and  withdrawal  of  the  needle.  The  infil- 
tration should  be  ample,  as  mentioned  in  connection  with  the  subcutaneous  injec- 
tions; however,  it  is  unnecessary  to  go  to  the  other  extreme  and  render  the  tissues 
edematous  as  in  the  Schleich  method.  The  pleura  and  peritoneum  never  require 
infiltration,  as  the  innervation  of  these  structures  is  derived  from  the  subpleural  or 


I 


VALVE,    INDICATIONS,   GENERAL    TECHNIQUE   OF   LOCAL   ANESTHESIA     189 

sul)i)oritoneal    eonnet'ti\e    tissue.      This    sini])le    j)r()ce(hirc    may    ho    amplified    l)y 
infiltration  of  parts  of  the  WxW  to  any  desired  extent  (Fig.  29). 

The  arrows  indicate  the  usual  direction  of  the  needle,  which  is  inserted  through 
two  wheals.  The  injection  is  begun  in  the  deepest  layer,  in  this  case  the  bone,  and 
finished  with  the  injection  of  the  subcutaneous  connective  tissue.  The  needle  is  there- 
fore inserted  through  one  of  the  indicated  points  into  the  subcutaneous  connective 
tissue,  then  perpendicularly  to  the  deepest  point — ^the  bone,  subperitoneal  connective 
tissue — and  the  injection  carried  out  as  for  simple  aspiration.  The  needle  is  then 
drawn  back  into  the  subcutaneous  connective  tissue  and  again  passed  to  the  same 
depth  but  in  a  more  oblique  direction  toward  the  centre  of  the  area  to  be  infiltrated. 
The  last  injection  is  made  directly  under  the  skin,  as  shown  in  (Fig.  19).  During  the 
insertion  and  withdrawal  of  the  needle  the  anesthetic  fluid  must  be  constantly  injected. 
If  the  needle  is  long  enough,  the  anesthesia  can  be  completed  from  one  wheal  placed 
either  at  the  end  or  in  the  centre  of  the  line  of  injection. 


Skin 
Subcutaneous 


I  tissue 


Fascia  and 
muscle 


Fig.  29. — Infiltration  of  a  plane  through  the  body  tissues. 


^.)    Bone 


It  is  never  necessary  in  any  part  of  the  body  to  inject  beneath  the  periosteum  to 
render  it  insensitive,  notwithstanding  the  fact  that  Reclus,  Schleich,  and  others, 
ad\ised  subperiosteal  injections  which,  from  a  practical  stand-point,  were  carried  out 
with  difficulty,  if  at  all.  The  skin  receives  its  innervation  from  the  underlying  sub- 
cutaneous connective  tissue,  for  which  reason,  if  the  latter  be  infiltrated,  the  skin 
becomes  anesthetized.  The  periosteum  receives  its  inner\'ation  from  without  and 
not  from  the  bone;  it  will  therefore  be  rendered  insensitive  if  the  tissues  overlying 
it  be  infiltrated.  Infiltration  of  the  thicker  layers  of  the  tissues  in  the  manner  described 
requires  considerable  practice ;  one  must  learn  to  feel  with  the  needle-point,  and  must 
know  at  all  times  where  the  point  of  the  needle  is,  for  which  reason  an  exact  knowledge 
of  anatomy  is  necessary.  The  hand  holding  the  syringe  must  be  able  to  detect  the 
minutest  change  of  structure,  as  when  the  needle-point  encounters  a  layer  offering 


190  LOCAL  ANESTHESIA 

certain  resistance  to  its  passage,  and  then  passes  into  a  connective  tissue  layer  of 
softer  and  looser  structure.  The  puncture  of  the  muscle  fascia  always  causes  slight 
pain.  To  avoid  injecting  larger  quantities  of  the  anesthetic  into  a  vein,  the  syringe 
must  be  in  constant  motion,  injecting  during  the  insertion  and  withdrawal  of  the  needle, 
as  has  already  been  recommended  by  Reclus  (injection  tra^ante  et  continue).  The 
continuous  injection  likewise  causes  an  even  distribution  of  the  anesthetic  in  the 
tissues. 

When  injections  are  to  be  made  in  the  neighborhood  of  large  vessels,  it  is  advisable 
to  insert  the  needle  first  w'ithout  the  s}Tinge,  and  if  no  blood  flows  from  the  needle, 
the  injection  should  be  made  during  its  withdrawal.  The  occasional  puncture  of 
large  arteries  or  veins  should  be  avoided.  This  accident,  according  to  our  experience, 
is  perfectly  harmless.    Of  course,  the  use  of  thin  needles  is  essential  (page  174). 

The  technique  of  the  injection  just  described  is  sufficient  for  infiltration  anesthesia 
of  a  narrow  line  of  incision  and  conduction  anesthesia  in  the  area  supplied  by  those 
nerve  trunks  which  have  been  affected  by  the  injection. 

The  first  is  practical  w^hen  a  simple  incision  is  to  be  made  through  normal  tissues, 
as,  for  instance,  the  removal  of  a  foreign  body  when  its  position  is  definitely  known. 
Conduction  anesthesia  produced  by  the  above-mentioned  infiltration  is  of  much  more 
importance  in  rendering  the  operative  field  insensitive. 

Occasionally,  by  a  simple  infiltration  of  a  narrow  area,  it  is  possible  to  interrupt 
the  larger  part  of  the  nerve  supply  to  the  operative  field.  This  is  made  use  of  in 
operations  in  the  anterior  triangle  of  the  neck  and  in  inguinal  and  femoral  hernia 
operations.  In  other  cases  several  areas  must  be  infiltrated  at  the  same  time,  which 
areas  may  be  some  distance  from  the  field  of  operation,  so  that  they  will  surround 
and  isolate  the  operative  field  from  the  rest  of  the  body. 

The  technique  of  these  procedures  can  be  more  definitely  shown  by  a  diagram. 
Fig.  30  represents  a  pyramid  wdth  apex,  5,  lying  in  the  depth  beneath  the  centre  of 
the  operative  field.  Its  base  1-2-3-4  is  located  upon  the  skin  surface;  its  lateral 
surfaces  bound  the  operative  field.  The  first  step  is  to  endeavor  to  anesthetize  these 
four  lateral  walls.  The  points  1-2-3-4  represent  the  points  for  injection.  A  long 
needle  is  inserted  into  each  one  of  the  before-mentioned  points  and  injections  made 
in  the  direction  of  point  5,  then  in  various  directions  from  the  laterally  located  points, 
as  1  to  7,  4  to  7,  4  to  6,  3  to  6,  3  to  9,  2  to  9,  etc.  The  subcutaneous  connective 
tissue  is  finally  infiltrated  in  the  form  of  a  Hackenbruch  rhombus,  in  the  directions 
1-2-3-4.  Shortly  after  the  injection  the  field  of  operation  becomes  insensitive, 
whether  it  has  come  into  contact  with  the  anesthetic  or  not. 

Two  points  of  injection  are  often  sufficient  for  the  injection  of  this  figure;  in  other 
cases  four  or  more  will  be  necessary,  depending  upon  the  extent  of  the  field  of  opera- 
tion.   Sometimes  it  will  take  the  form  of  a  cone  or  a  part  of  it,  at  other  times  a  trough- 


VALUE,    IXDICATIOXS,   GENERAL    TECHSIQVE   OF   LOCAL   ANESTHESIA     191 

like  shape,  as  is  shown  in  Fig.  ol.  Two  points  of  entrance  are  desiiinated  in  the  (ha- 
gram  by  1  and  2.  From  these  points  injections  are  made  in  the  (Hrections  'A,  4,  5,  0,  7, 
and,  lastly,  the  subcutaneous  tissue  is  infiltrated  in  the  form  of  a  Hackenbruch 
rhombus.  Fig.  32  shows  how,  in  the  case  of  bone,  the  operative  field  is  surrounded  by 
an  encasing  form  of  injcc-tion  which  renders  all  ])arts  of  the  operative  field  insensiti\-e. 


Fig.  30. — Pj-ramidal  form  of  injection. 

For  all  these  injections  0.5  per  cent,  novocain-suprarenin  solution  is  the  most  suit- 
able anesthetic;  it  interrupts  the  conducti\ity  of  small  and  medium-sized  nerve 
trunks  quickly  and  with  certainty  if  the  connective  tissue  layers  containing  the 


nerve  trunks  are  infiltrated  without  necessarily  hunting  these  nerves.  Concentrated 
solutions  of  novocain-suprarenin  (1  to  4  per  cent.)  are  recommended  in  cases 
where  large  quantities  of  fluid  might  cause  discomfort  or  injury,  as  in  the  orbit, 
eyelids,  prepuce,  the  fingers,  etc.    It  must  be  remembered  that  these  concentrated 


192 


LOCAL  ANESTHESIA 


solutions  produce  considerable  effect  on  tissues  situated  at  some  distance  from  the 
place  of  injection.  An  injection  of  such  a  solution  after  a  short  time  produces  infiltra- 
tion anesthesia  not  only  in  the  area  injected  but  likewise  for  some  distance  beyond, 
and  nerve  trunks  will  be  blocked  if  passing  through  this  area  by  the  so-called  indirect 
infiltration  anesthesia.    ]\Iuch  use  is  made  of  this  method  in  practice. 


Fig.  32.— Encasing  injMtioi 


The  combination  of  direct  anesthesia  of  the  larger  nerve  trunks  in  connection  with 
the  circuminjection  of  the  operative  field  requires  definite  rules  for  its  performance 
and  is  accomplished  by  a  definite  guidance  of  the  needle.  Seeking  the  nerve  trunks 
with  the  point  of  the  needle  is  easy  and  certain  when  the  position  of  the  nerve  can 
be  definitely  located  in  connection  with  bony  landmarks  which  aid  in  the  guidance 
of  the  needle.  It  is  much  more  difficult  when  these  landmarks  are  absent  and  the 
nerve  is  situated  in  the  midst  of  thick  soft  parts.  A  good  guide  in  all  cases  is  the 
radiation  of  sensations  of  paresthesia  toward  the  periphery,  which  occurs  following 
the  irritation  of  the  nerve  with  the  needle.  If  possible,  the  patient  must  be  instructed 
in  this  regard  before  the  introduction  of  the  needle,  and  must  be  told  to  speak  at 
once  as  soon  as  he  notices  the  paresthesia.  If  these  sensations  occur,  it  is  certain 
that  the  point  of  the  needle  is  in  the  proper  place.  For  the  blocking  of  large  nerve 
trunks  it  is  advisable  to  use  concentrated  solutions,  as  1  to  5  c.c.  of  a  2  to  4  per  cent. 


VALUE,   IXDICATIOXS,   GENERAL   TECHNIQUE  OF  LOCAL  ANESTHESIA      193 

novocaiii-suprarenin  solution.  The  length  of  time  necessary  after  the  injection  for 
blocking  to  occur  depends  upon  how  the  nerve  was  reached.  If  the  needle  can  be 
introduced  into  the  nerve  trunk,  as  is  possible  after  a  little  practice,  for  instance, 
with  the  branches  of  the  trigeminus,  the  interruption  of  conduction  occurs  instantly. 
If  the  anesthetic  is  injected  only  in  the  neighborhood  of  nerves,  it  will  require  five 
to  twenty  minutes  before  it  interrupts  the  conductivity  of  the  nerve. 

Freely  exposed  nerve  trunks  can  be  instantly  blocked  if  one  injects  into  the  trunk 
a  0.5  or  1  per  cent,  novocain-suprarenin  solution.  A  spindle-shaped  swelling  of  the 
ne^^•e  occurs  which  disappears  very  quickly.  It  seems  as  though  the  injected  fluid 
is  disseminated  between  the  nerve  bundles.  It  can  therefore  happen  that,  after  an 
endoneural  injection,  branches  of  the  nerve  may  be  interrupted  which  leave  the 
trunk  proximal  to  the  point  of  injection.  The  method  of  injection  in  individual 
cases,  whether  it  be  infiltration,  circuminjection,  or  blocking  of  the  nerve  trunks  for 
the  purpose  of  rendering  the  operative  field  insensitive,  whether  it  deals  with  injury, 
removal  of  a  foreign  body,  inflammatory  conditions  or  tumors,  is  the  same.  The 
nature  of  the  anesthesia  wull  be  seldom  influenced  by  the  nature  of  the  disease. 

Care  must  be  taken  to  infiltrate  a  sufficiently  large  area  around  the  operative  field, 
allowing  a  certain  amount  of  play,  as  it  were,  so  as  not  to  be  cramped  for  room,  for 
w^hich  reason  the  lines  for  circuminjection  should  never  be  too  near  the  line  of  incision. 
That  no  injections  should  be  made  too  near  diseased  tissues  has  been  repeatedly  men- 
tioned, and  injection  into  the  diseased  tissues  themselves  is,  of  course,  not  permissible. 
This  latter  applies  particularly  to  septic  infections.  A  small  circumscribed  furuncle 
can  be  injected  in  the  form  of  a  pyramid  if  the  inflamed  tissues  are  avoided;  diffuse 
phlegmons  are  only  suitable  for  anesthesia  when  nerve  blocking  can  be  accomplished 
some  distance  from  the  operative  field.  Local  anesthesia  is  not  contra-indicated  for 
malignant  growths  if  the  entire  operative  field  can  be  excluded  without  injecting 
into  the  immediate  neighborhood  of  the  tumor. 

In  excision  of  cystic  tumors,  retention  cysts,  bursae,  etc.,  it  is  sometimes  advisable 
to  deviate  from  the  rule  of  completing  the  injections  before  operation,  if  the  injection 
is  made  with  difficulty.  In  these  cases  the  approach  to  the  cyst  is  made  insensitive, 
and,  after  opening  it,  the  surrounding  parts  are  infiltrated  from  its  inner  surface  before 
resecting  the  sac.  Naturally,  after  making  the  second  injection  time  must  be  given 
for  it  to  act. 

It  is  needless  to  say  that  the  operative  fields  most  suitable  for  this  method  of  anes- 
thesia are  those  where  innervation  can  be  readily  interrupted,  as  will  be  specified 
in  the  following  chapters.  The  anesthesia  of  synovial  membranes  in  aseptic  joint 
operations  has  already  been  mentioned  on  page  147.  Anesthesia  for  fractures  and 
dislocations  will  be  described  according  to  the  method  of  Quenu  and  Lerda  in 
Chapter  XYI. 
13 


CHAPTER   XL 

OPERATIONS  ON  THE   HEAD. 

The  head  receives  its  sensory  innervation  chiefly  through  the  trigeminus  nerve. 
The  occipital  region,  region  of  the  ears,  and  the  under  border  of  the  lower  jaw  also 
receive  innervation  from  the  spinal  nerves  (occipitalis  major  and  minor,  auricularis 
magnus,  and  cutaneus  colli).  The  trigeminus  nerve  innervates,  besides  the  skin  of 
the  face,  the  bones  and  cavities  of  this  part  and  the  organs  contained  in  them.  The 
base  of  the  tongue,  pharynx,  middle  and  inner  ear  are  inner\'ated  by  the  glosso- 
pharyngeal nerve,  while  the  vagus  supplies  the  sensory  innervation  to  the  outer  ear 
and  drum. 


OPERATIONS    UPON    THE   SCALP,    FOREHEAD    AND   SKULL. 

As  will  be  noted  in  Eig.  33,  the  sensory  nerves  supplying  the  forehead,  temporal 
region,  and  the  scalp  emerge  and  pass  through  the  fascia  and  skin  on  a  line  approxi- 
mately drawn  from  the  occipital  protuberance  to  the  eyebrow,  encircling  the  skull. 
They  pass  in  a  direction  toward  the  crown  of  the  head  where  they  subdivide.  In  this 
entire  distribution  the  nerves  are  subcutaneous,  that  is,  subfascial;  for  which  reason 
an  anesthetic  area  of  any  desired  extent  can  readily  be  produced  by  interrupting 
these  nerves.  These  same  nerves  innervate  not  only  the  skin  and  fascia  but  likewise 
the  bone  and  periosteum  of  the  crown  of  the  head.  The  dura  mater  is  only  sensitive 
toward  the  base  of  the  skull.  The  brain,  as  has  been  previously  mentioned,  is  insensi- 
tive to  all  irritation  (see  page  35).  For  this  reason  the  simple  subcutaneous  or  sub- 
fascial circuminjection  is  sufficient  to  render  anesthetic  an  operative  field  of  any 
desired  size  for  skull  and  brain  operations.  Only  in  those  places  where  the  skull 
is  covered  by  muscle  layers  will  it  be  found  necessary  to  anesthetize  these  structures 
by  an  additional  line  of  infiltration  anesthesia.  The  circuminjection  of  a  line  running 
bilaterally  from  the  eyebrows  above  the  outer  ear  to  the  occipital  region  will  render 
the  entire  top  of  the  skull  insensitive.  The  modern  anesthetic  agents  permit  us  to 
inject  an  area  of  this  extent  without  fear.  Subperiosteal  injections  are  never  necessary 
and  serve  no  purpose. 

The    circuminjection   with    novocain-suprarenin    solution    serves    not    only    for 


OPERATIOXS  OX   THE  HEAD 


195 


produciiii;'  aiu'sthcsia,  hut  inasimicli  as  tlit-  arteries  supplvinj;-  the  skull  run  radiall}-  in 
the  same  direction  as  the  nerves,  they  will  undergo  contraction,  and  as  a  result  the 
operative  field  will  he  rendered  bloodless.  For  this  reason  local  anesthesia  in  skull 
operations  makes  the  use  of  various  devices  for  stopping  hemorrhage  unnecessary, 
such  as  the  temporary  suturing  of  the  scalp  alone  (Heidenhain),  or  in  connection  with 
metal  plates  (Kredel),  or  the  clamping  of  the  wound  margins  with  spring  clamps 
(A\)rschuetz).  Complete  interruption  of  the  circulation  does  not  occur  and  should 
not  occur  from  this  method  of  injection.  The  larger  arteries  bleed  slightly  and  must 
be  ligated;  hemorrhage  from  the  smaller  vessels,  however,  is  absent.  This  method 
in  skull  operations  is  sufficient  and  possesses  many  advantages  over  the  unsatisfactory 
proxisional  methods  for  stopping  hemorrhage. 


^m 

^ 

mff0SS/m 

5Ka\ 

^^^■K   '     r 

^  -1l 

f             K 

fij' 

;- 

Fig.  33.— Points  of  cmergfii 
skin  and  aponeurosis  of  the  (»■ 
(second  branch  of  the  trigcnii 
magnus;  6,  occipitalis  minor;  7, 
nasal  branches  of  the  ethmoid; 


use  under  the 
laticotemporal 
"),  auricularis 
i! ;  10,  external 


For  the  circuminjection  of  small  operative  fields  the  0.5  per  cent,  novocain-supra- 
renin  solution  is  sufficient,  but  in  larger  and  more  vascular  areas  the  use  of  1  per  cent, 
novocain-suprarenin  solution  should  be  preferred  owing  to  its  better  blood-stilling 
properties. 

Brain  Puncture. — A  wheal  is  made  at  the  point  of  the  contemplated  puncture  and 
an  injection  of  a  few  cubic  centimeters  of  a  O.o  per  cent,  novocain-suprarenin  solu- 
tion is  made  beneath  this  wheal. 


196 


LOCAL  ANESTHESIA 


Extirpation  of  Atheromata. — Two  points  for  injection  are  chosen  which  correspond 
to  the  ends  of  the  proposed  Hne  of  incision  (Fig.  34).  From  these  points  injections 
are  made  in  a  rhombic  or  quadrilateral  form,  injecting  10  to  30  c.c.  of  a  0.5  per  cent, 
novocain-suprarenin  solution  in  the  direction  of  the  dotted  line. 


Fig.  34. — Anesthesia  for  an  athen 


Methods  to  be  Used  in  Extensive  Injury  of  the  Soft  Parts,  or  Complicated  Frac- 
tures of  the  Skull. — In  the  neighborhood  of  the  injury  a  number  of  points  of  entrance 
are  marked  by  wheals  which  completely  surround  the  operative  field.  As  shown  in 
Fig.  35,  six  points  are  made.  They  should  not  be  farther  separated  from  one 
another  than  the  curvature  of  the  skull  will  permit  in  connecting  these  points  with  a 
straight  needle  beneath  the  fascia.  From  these  points  the  loose  subfascial  tissue 
should  be  injected  in  the  form  of  a  narrow  line  completely  surrounding  the  operative 
field  in  the  direction  indicated  by  the  dotted  line  and  infiltrated  with  a  1  per  cent, 
novocain-suprarenin  solution.  After  the  injection  the  skin  of  the  injected  strip  is 
raised  in  the  form  of  a  narrow  wall  above  the  surface  of  the  surrounding  skin.  In 
one  or  two  minutes,  however,  this  elevation  disappears.  About  5  c.c.  of  this  solution 
should  be  injected  to  each  5  cm.  of  the  proposed  line  of  injection.  In  this  instance 
about  40  c.c.  of  a  1  per  cent,  novocain-suprarenin  solution  will  be  necessary.  In 
all  cases  the  line  of  circuminjection  must  be  so  made  that  all  accessory  incisions, 
no  matter  how  far  removed  from  the  wound,  will  be  included  within  this  area  before 
beginning  the  operation.  The  anesthesia  of  this  operative  field  is  complete  after  a 
few  minutes. 

In  \'ery  severe  head  injuries,  in  which  the  patient  is  comatose,  anesthesia  of  any 
sort  is  unnecessary,  while  in  those  partially  conscious  it  may  at  times  be  necessary 


OPERATIONS  ON  THE  HEAD 


197 


to  use  light  general  anesthesia  in  adtlition,  but  even  in  these  cases  we  use  the  method 
of  circuminjection  on  account  of  the  bloodlessness  of  the  operative  field.  For  the 
repair  of  the  majority  of  head  injuries  general  anesthesia  is  unnecessary. 


Fig.  35. — Circuminjection  of  a  complicated  fracture  of  the  skull. 


Extirpation  of  a  Rodent  Ulcer  of  the  Scalp  with  Resection  of  the  Skull. — In  this 
case  the  tumor  was  removed  along  with  a  section  of  bone  7^  c.c.  in  diameter;  the  dura 
was,  as  usual  in  this  region,  insensitive.  Fig.  36  shows  the  patient  after  healing; 
the  skin  defect  was  covered  by  epithelial  grafts.  This  operation  was  done  in  1905 
in  the  days  of  cocain  anesthesia,  and  was  probably  the  first  resection  of  the  skull 
performed  under  local  anesthesia.  The  circuminjection  as  shown  in  the  figure  was 
carried  out  from  six  points  30  c.c.  of  a  0.2  per  cent,  cocain  solution  with  0.1  mg.  of 
suprarenin  were  used.  At  the  present  time  30  to  50  c.c.  of  a  1  per  cent,  novocain- 
suprarenin  solution  would  be  used. 

Extensive  Resection  of  the  Skull  with  Repair  of  the  Dura  and  Plastic  Skin  Flap.— 
The  case  was  one  of  a  large  carcinoma  of  the  right  side  of  the  roof  of  the  skull,  spring- 
ing from  the  periosteum  and  adherent  to  the  skin  (Fig.  37).  This  large  defect  after  the 
extirpation  was  covered  with  a  pediculated  skin  flap  taken  from  the  left  side  of  the 
occipital  region;  no  attempt  was  made  to  replace  the  bone.     For  this  purpose  the 


198 


LOCAL  ANESTHESIA 


Fig.  36. — Circumiujection  for  resection  of  the  skull  for  rodent  ulcer. 


Fig.  37. — Sarcoma  of  the  skull,  showing  half  of  the  circuminjection  figure.    The  other  half  includes 
the  flap  u.sed  for  plastic  repair  of  defect. 


OPERATIONS  ON  THE  HEAD 


\m 


entire  roof  of  the  skull  was  surrounded  by  a  line  of  infiltration,  only  half  of  the  i)oints 
for  injeetion  and  line  of  injection  being  shown  in  Fig.  ;^5.  Above  the  zygoma  and  in 
the  occipital  region  the  parts  were  injected  not  only  subcutaneously  but  also  intra- 
muscularly, as  will  be  more  fully  described  in  the  next  case;  75  c.c.  of  a  1  per  cent, 
novocain-suprarenin  solution  were  used. 

This  operation,  which  was  performed  in  1911,  was  painless  and  free  from  an  appre- 
ciable loss  of  blood.  The  skin  surrounding  the  tumor  was  incised  and  the  bone  in 
the  same  area  was  outlined  with  Borchardt's  forceps;  the  dura  was  finally  excised, 
as  it  was  found  to  be  adherent  to  the  tumor.  As  usual,  the  excision  of  the  dura  in 
the  temporal  region  above  the  zygoma  caused  slight  pain,  whereas  its  separation 
from  the  upper  portion  of  the  skull  w^as  absolutely  insensitive.  Fig.  38  shows  the 
tumor  with  the  resected  portion  of  the  dura  adherent  to  it.    Fig.  39  shows  the  patient 


.   .    ,  T  .   . 

.  .  '^(^ .  i 

,f:m^ 

iin 

W^ 

Fig.  38. — Sarcoma  of  the  skull,  showing  section  i\ 


after  removal  of  the  tumor.  The  flattening  of  the  exposed  surface  of  the  brain  due  to 
the  pressure  of  the  growth  is  easily  observed.  Fig.  40  shows  the  patient  with  the  skin 
flap  ready  to  be  placed  in  position.  This  was  done  after  the  defect  in  the  dura  was 
closed  by  a  piece  of  the  fascia  lata,  which  was  also  removed  under  local  anesthesia. 
The  patient  is  sitting  upright  on  the  operating-table  unaided,  save  for  the  head,  wdiich 
is  being  held  by  an  assistant  for  the  purpose  of  being  photographed.  The  operation 
was  concluded  by  sewdng  the  skin  flap  in  the  defect  of  the  right  half  of  the  scalp,  and 
co^•ering  the  secondary  defect  by  epithelial  grafts  taken  under  local  anesthesia. 

Fig.  41  shows  the  patient  after  healing,  which  occurred  by  primary  intention,  with 
the  exception  of  a  small  marginal  area  of  the  transplanted  flap  which  became  gan- 
grenous.   Although  the  transplanted  piece  of  fascia  was  exposed  to  the  air  for  a  time 


fM 

g 

1 

S 

P 

a;< 

S^^ 

•^ 

1 

P' 

\v' 

V 

F 

Fig.  39. — Sarcoma  of  the  skull,  showing  patient  after  removal  of  the 


Fig.  40. — Sarcoma  of  the  skull,  after  transplantation  of  fascia  for  covering  the  defect  in  the  dura, 
and  the  skin  flap  separated. 


OPERATIONS  ON  THE  HEAD 


201 


it  nevertheless  retained  its  vitality  and  became  covered  with  epithelium.    The  photo- 
graphs show  that  the  hemorrhage  was  A-ery  slight  owing  to  the  use  of  local  anesthesia. 


Resection  of  the  Skull  in  the  Temporal  Region. — The  auther  has  frequently  per- 
formed operations  in  this  region,  usually  for  the  purpose  of  removing  an  epidural  hema- 
toma, and  once  for  the  removal  of  a  foreign  body  which  lay  exactly  in  the  centre  for 
speech,  after  which  the  motor  aphasia  disappeared.  Everyone  of  these  operations 
demonstrated  the  fact  that  the  dura  toward  the  base  was  distinctly,  if  only  slightly, 
sensitive  to  pain.  Fig.  42  shows  the  arrangement  of  the  wheals  and  the  circuminjection 
figure  used  in  the  excision  of  a  bone-muscle  flap  in  the  temporal  region.  Point  1  lies  in 
the  middle  of  the  upper  border  of  the  zygoma  and  from  this  point  a  0.5  or,  better,  a  1  per 
cent,  novocain-suprarenin  solution  is  injected  not  only  subcutaneously  in  the  direction 
of  the  dotted  line  indicated  in  the  diagram  but  also  transversely,  the  line  of  infiltra- 
tion extending  through  the  temporal  muscles,  according  to  Fig.  43.  The  cut  shows 
schematically  a  trans\'erse  section  through  the  skin,  temporal  muscle  and  temporal 
bone  made  from  wheal  1 ;  this  line  corresponds  to  the  upper  border  of  the  zygoma 
and  parallel  with  it.  From  point  1,  the  needle  is  first  inserted  perpendicularly  to  the 
skin  surface  until  it  reaches  the  bone  (arrow  1),  then  in  a  more  oblique  direction  toward 
the  anterior  and  posterior  edge  of  the  temporal  muscle,  until  bone  is  again  felt  (arrow 
2).  The  injections  are  all  made  in  the  same  horizontal  plane.  Finally,  the  last 
injection  is  made  beneath  the  subcutaneous  connective  tissue  (arrow  3)  toward  points 


202 


LOCAL  ANESTHESIA 


2  and  6  (Fig.  42).  For  the  injection  from  point  1,  about  30  c.c.  of  the  solution  are 
necessary;  for  the  subcutaneous  circuminjection  of  the  operative  field  another  30  c.c. 
Therefore  at  least  GO  c.c.  of  novocain-suprarenin  solution  are  necessary  for  the  entire 
injection. 


Fig.  42. — Wheals  marking  the  points  for  injection  and  the  location  of  the  skin  incision  for  resections 
of  the  skull  in  the  temporal  region. 


Fig.  4.3.— tt,  skin;  h,  .ulm 


d,   tenipoial  hone. 


( i(i-->  -i  Liion  ot  the  temporal  muscle; 


Krause   has   recently   reported   the    excision   of   the    Gasserian   ganglion    under      ( 
local   anesthesia,  with   the  patient  previously  prepared   by  the  administration  of 


OPERATIONS  ON  THE  HEAD 


203 


pantopon-scopolamin.  It  is  advisable  in  this  operation  not  only  to  eirenniinject 
the  field  of  operation  but  also  to  block  the  mandibular  ner\e  in  the  foramen  o\ale 
or  to  inject  the  Gasserian  ganglion  direct,  according  to  the  method  of  Haertel.  This 
method  will  scarcely  require  further  consideration,  as  it  is  possible  to  reach  the  trunk 
of  the  trigeminus  at  its  point  of  exit,  or  puncture  the  ganglion  direct,  after  which 
alcohol  is  injected,  which  destroys  the  ganglion  without  extir])ating  it. 


Kisure  of  the  cerebcUun 


Exposure  of  the  Cerebellum. — The  author  has  performed  this  operation  5  times  under 
local  anesthesia  without  causing  any  pain  whatever.  Like  success  was  also  noted  in  two 
previous  case  reports.  The  simultaneous  suprarenin  anemia  is  of  the  greatest  impor- 
tance in  these  operations,  as  it  makes  it  unnecessary  to  postpone  opening  the  skull  until 
a  subsequent  time.  Fig.  44  shows  the  arrangement  of  the  points  for  injection  and  the 
line  of  incision  for  the  exposure  of  both  hemispheres  of  the  cerebellum.  It  is  advis- 
al)le  not  to  depart  from  the  arrangement  as  shown  in  the  diagram  even  if  only  half 
of  the  cerebellum  is  to  be  operated  upon.  The  points  3  and  9  lie  immediately  back 
of  the  base  of  the  mastoid  process.    From  these  two  points,  as  well  as  from  the  points 


204  LOCAL  ANESTHESIA 

1,  2,  and  10,  the  necessary  injections  are  made  into  the  muscles  of  the  neck.  The  object 
of  these  injections  is  to  infiltrate  the  muscle  layers  with  suprarenin  solution  in  a  cup- 
shaped  manner,  which  isolates  the  operative  field  from  the  rest  of  the  body.  The 
operative  field  itself  is  not  injected.  The  direction  of  the  needle  in  this  injection  is 
analogous  to  that  of  the  temporal  muscles  (Fig.  43) .  The  needle-point  must  always 
be  inserted  as  far  as  the  transverse  processes  of  the  cervical  vertebrae  and  the  occiput. 
The  connections  of  the  various  points  of  injection  are  made  subcutaneously.  It  will 
be  necessary  to  use  between  100  to  120  c.c.  of  solution,  more  than  half  of  which  is 
used  for  the  injection  of  the  muscles  of  the  neck.  The  0.5  per  cent,  novocain-supra-  . 
renin  solution  will  cause  complete  anesthesia  and  anemia.  The  dura  of  the  posterior 
fossa  of  the  skull  and  cerebellum  are  insensitive. 

In  resections  of  the  skull  under  local  anesthesia  the  use  of  the  chisel  should  be 
limited  as  far  as  possible,  as  its  manipulation  is  very  unpleasant  to  the  patient. 
The  use  of  morphin,  pantopon-scopolamin,  etc.,  in  patients  with  brain  injuries  and 
affections  causing  pressure  should  be  avoided  owing  to  the  unfavorable  action  on 
the  respiratory  centre.  If  the  operator  confines  himself  to  the  use  of  the  saw  and 
bone-forceps,  patients  do  not  complain  of  skull  and  brain  operations  carried  out 
under  local  anesthesia. 

Bier  has  recently  reported  operations  on  the  cerebrum  under  local  anesthesia. 
He  found  that  the  irritability  of  the  cortex  was  diminished,  even  though  the  injec- 
tions were  made  on  the  outer  surface  of  the  skull.  If  this  observation  proves  to  be 
correct,  local  anesthesia  will  not  be  suitable  in  operations  for  epilepsy. 


OPERATIONS  UPON  THE  ORGANS  OF  HEARING. 

The  muscles  of  the  ear  are  innervated  by  the  auricularis  magnus,  auriculotemporalis, 
occipitalis  minor,  and  the  auricular  branch  of  the  vagus.  The  skin  and  bony  canal 
of  the  ear  as  well  as  the  outer  surface  of  the  drum  are  innervated  by  branches  of  the 
auriculotemporalis  and  the  auricular  branch  of  the  vagus  passing  from  the  skin  and 
bony  canal  into  the  organs  of  hearing.  The  inner  surface  of  the  drum,  the  mucosa 
of  the  antrum,  epitympanic  recesses,  and  the  Eustachian  tube  are  innervated  by 
the  tympanic  branch  of  the  glossopharyngeal  nerve.  The  mucous  membrane  of  j 
the  mastoid  cells  and  of  the  antrum  of  the  tympanum  is  innervated  by  the  nervus 
spinosus,  a  branch  of  the  mandibular,  which  passes  from  the  cranial  cavity  through 
the  petrosal  fissure  into  the  temporal  bone.^ 

1  It  is  impossible  for  the  author  at  this  time  to  consider  extensively  anesthesia  in  connection  with  the 
so-called  special  operation,  as  he  has  not  had  sufficient  personal  experience. 


OPERATIONS  ON  THE  HEAD 


205 


Anesthesia  of  the  Membrana  Tympani. — The  ear-drum  reacts  but  slightly  to 
anesthetic  agents  (cocain  or  ahi)in)  applied  to  its  surface,  owing  to  its  protective 
epidermis.  Applications  of  carbolic  acid  are  much  more  effective  (Bonain),  or  a  com- 
bination as  recommended  by  Hechinger  can  be  used,  which  consists  of  acid,  carbol. 
0.5,  cocain  muriat.  menthol  aa  2.0,  alcohol  10.0.  This  solution  is  applied  to  the  drum 
by  means  of  small  tampons. 

Paracentesis  and  incision  of  furuncles  can  usually  be  made  without  pain.  Tiefen- 
thal,  for  anesthetizing  the  drum  for  paracentesis,  injected  2  to  4  drops  of  a  5  to  10 
per  cent,  cocain-suprarenin  solution  with  a  fine  needle  into  the  tympanic  cavity. 
Albrecht  used  cataphoresis  for  anesthesia  of  the  drum.  He  saturated  a  cotton  appli- 
cator, attached  to  the  positive  electrode  with  a  20  per  cent,  cocain  solution  and 
applied  it  to  the  drum.     After  three  or  four  minutes  it  w^as  insensitive. 


—Van  Eicken's  inject 
of  the  auditory  ( 


I  for  anesthesia 


-Anesthesia  of 
of  the  ear. 


Anesthesia  of  the  External  Auditory  Canal.— Complete  anesthesia  of  the  external 
auditcjry  canal  can  easily  be  obtained  by  an  injection  of  the  anesthetic  near  the  bone, 
both  in  front  of  and  behind  the  canal,  as  recommended  by  Eicken  and  Laval.  By  means 
of  this  injection  the  vagus  and  auriculotemporalis,  which  supph'  the  auditory  canal, 
are  blocked.  The  point  for  injection  lies  in  front  of  the  tip  of  the  mastoid  behind  the 
attachment  of  the  ear.  The  lobule  is  drawn  forward  and  outward,  the  needle  is  then 
directed  along  the  anterior  surface  of  the  mastoid  process,  passing  the  auditory  canal, 
to  the  temporal  line;  1  or  2  c.c.  of  a  2  per  cent,  novocain-suprarenin  solution  are 
injected.  The  needle  is  then  passed  in  a  line  near  the  front  of  tlie  auditory  canal  and 
back  of  the  maxillary  articulation  as  far  as  the  junction  of  the  zygoma  with  the 


206  LOCAL  ANESTHESIA 

temporal  bone  (Fig.  45).  In  making  the  anterior  injection,  Eicken  and  Laval 
recommend  that  the  mouth  be  open,  so  that  the  head  of  the  inferior  maxillary 
bone  will  be  pushed  forward.  Sensation  in  the  drum  will  be  diminished'-after  this 
injection  but  not  entirely  lost. 

Anesthesia  of  the  External  Ear. — By  means  of  a  subcutaneous  injection  carried 
out  from  two  points  around  and  under  the  attachment  of  the  ear  (Fig.  46),  using 
about  20  c.c.  of  a  0.5  or  1  per  cent,  novocain-suprarenin  solution,  the  entire  external 
ear  may  be  rendered  insensitive. 

Anesthesia  of  the  Tympanic  Cavity. — In  case  of  destruction  of  the  drum  the  mucous 
membrane  of  the  tympanic  ca\'ity  can  be  anesthetized  by  dropping  into  the  ear  a  few 
drops  of  a  10  to  20  per  cent,  solution  of  cocain  or  alypin.  The  complicated  shape 
of  this  cavity  makes  it  difficult  to  obtain  an  even  distribution  of  the  anesthetic  which 
not  infrequently  interferes  with  complete  anesthesia.  Tiefenthal's  injection  through 
the  unruptured  drum  has  already  been  mentioned.  Neumann  claims  that  if  fluid 
be  injected  beneath  the  upper  wall  of  the  external  auditory  canal,  the  soft  parts  will 
be  separated  from  the  bone  and  the  fluid  must  pass  under  the  drum  membrane  and 
the  mucous  membrane  of  the  tympanic  cavity,  and  in  this  manner  cause  both  the 
drum  and  the  tj-mpanum  to  become  completely  anesthetized. 

Neumann  has  described  this  injection  as  follows:  The  needle  is  passed  through 
the  cartilage  and  beneath  the  periosteum  of  the  upper  wall  of  the  external  auditory 
canal  about  0.5  to  1  cm.  from  the  beginning  of  the  bony  part.  This  point  of  injection 
can  be  readily  determined  by  moving  the  ear  up  and  down,  the  cartilaginous 
portion  forming  a  fold  where  it  adjoins  the  bony  part.  Another  means  of  dis- 
tinguishing this  boundary  is  the  dift'erence  in  appearance  between  the  cartilaginous 
and  the  bony  part  of  the  canal.  The  former  appears  dull,  while  the  latter  is 
glossy.  After  fixing  the  point  for  injection,  the  needle  is  passed  in  an  oblique 
direction  upward  until  the  bony  canal  is  felt;  the  anesthetic  solution  is  then  injected 
under  medium  pressure.  It  will  be  necessary  to  wait  about  ten  minutes  before 
anesthesia  is  complete. 

The  method  of  Neumann  has  been  used  with  marked  success  in  Politzer's 
clinic  for  operations  upon  the  internal  ear,  as  in  the  removal  of  the  hammer  and 
anvil,  etc.  Gompertz,  Thies,  Halacz,  Barany,  Harley,  and  others,  have  stated 
that  a  very  satisfactory  anesthesia  of  the  drum  and  tympanic  cavity  can  be 
obtained  by  means  of  the  Neumann  injection  in  combination  with  the  application 
of  strong  anesthetics. 

The  Chiselling  of  the  Mastoid  Process,  Opening  of  the  Tympanic  Cavity  and  the 
Radical  Mastoid  Operation.  —  We  will  now  consider  the  most  extensive  of  these 
operations,  which  will  suffice  for  all  the  minor  operations  in  this  region.  The  attempts 
of  Alexander  to  perform  the  radical   mastoid  operation   by  means   of  Schleich's 


I 


()PERATI().\S  ON   TIU'J  II KM) 


207 


infiltration  anesthesia  has  not  found  many  fohowers.  It  was  throutih  the  work  of 
Xeuinanu  that  progress  was  made  in  this  cUreetion,  wliieli  eonsisted  in  the  eireum- 
injection  of  the  external  auditory  canal,  as  already  described  by  Eicken  and  Laval, 
combined  with  anesthesia  of  the  drum  and  tympanic  cavity  by  means  of  the  Neu- 
maini  injection,  thus  producing  complete  anesthesia  of  the  ear  muscles,  the  soft 
]iarts  oAerlying  the  bone,  and  the  internal  ear.  Kulenkampff  used  this  method  in 
his  series  of  30  radical  operations.  The  author  has  also  used  this  method  and  can 
state  that  the  results  haNc  been  very  good  in  cases  in  which  the  above-mentioned 
technicjue  has  been  carried  out.  He  also  recommends  the  following  procedure, 
which  in  principle  has  been  suggested  by  Neumann: 

With  the  patient's  head  lying  on  the  healthy  side,  begin  by  instilling  a  few  drops 
of  a  20  per  cent,  alypin  or  cocain  solution  with  the  addition  of  suprarenin  into  the 
external  auditory  canal.  Inasmuch  as  the  drum  is  usually  destroyed,  the  solution 
itself  enters  the  tympanic  cavity  and  can  act  upon  the  mucous  membrane  during 
the  subsequent  injection.     This  is  not  always  necessary. 


-ction  of  tlie  opo 


■:il  mastoid  operation. 


The  circuminjection  of  the  entire  operative  field  is  carried  out  from  3  or  4  points 
as  shown  in  Fig.  47.  It  will  be  necessary  to  use  40  c.c.  of  a  0.5  per  cent,  novocain- 
suprarenin  solution  for  this  injection,  more  than  half  of  which  should  be  used  along 
the  lower  border  of  the  operative  field  in  the  region  of  the  occipital  and  great 
auricular  nerves.  Injections  in  the  line  of  incision,  as  recommended  by  Neumann, 
are  not  necessary.  The  photograph,  as  shown  in  Fig.  48,  was  made  immediately 
after  the  injection  and  shows  this  surface  raised  above  the  surrounding  skin;  this 


LOCAL  ANESTHESIA 


condition  disappeared  within  a  few  minutes.     It  will  now  be  necessary  to  anesthetize 
the  auditory  canal,  which  is  done  in  the  following  manner:  With  the  ear  drawn  for- 


FiG.  48. — Appearance  of  the  operative  field  for  the  radical  mastoid  operation  immediatelj'' 
after  injection 


Fig.  49. — Position  of  the  point  of  injection  back  of  the  auditory  canal. 


ward,  a  point  of  entrance  is  marked  just  behind  the  ear  (Fig.  49),  the  needle  is  passed 
along  the  anterior  surface  of  the  mastoid  process  as  far  as  the  bony  canal,  and  2  c.c. 
of   a  2   per   cent,   novocain-suprarenin   solution  injected.     This  injection  requires 


OPERATIONS  ON  THE  HEAD  209 

c()iisitleral)lc  pressure,  for  which  reason  the  sokitiou  will  he  evenly  distrihuted  around 
the  entire  eanal.  This  is  followed  by  the  })reviously  described  Neumann  injection 
(2  c.c.  of  a  2  per  cent,  novocain-suprarenin  solution)  in  the  ni)per  wall  of  the  canal. 
The  latter  is  painless  because  the  canal  has  already  been  rendered  insensitive.  It  is 
also  necessary  to  make  an  injection  of  1  to  2  c.c.  of  a  2  per  cent.  no\()cain-suprareiiin 
solution  from  within,  along  the  anterior  wall  of  the  canal. 

If  this  injection  has  been  properly  made,  the  incision  of  the  soft  parts,  the  separation 
of  the  periosteum,  the  separation  of  the  membranous  portion  of  the  canal  from  the 
bony  portion,  and  any  plastic  incisions,  wall  be  absolutely  painless.  Following  the 
suggestion  of  Dr.  Ivulenkampff  the  latter  incision  should  be  completed  before  begin- 
ning the  operation  on  the  bone,  which  permits  a  much  better  approach  to  the  rest  of 
the  field  of  operation.  If  a  traction  suture  is  passed  through  the  membranous  part 
of  the  canal,  after  its  incision,  the  ear  and  canal  can  be  easily  held  forward  without 
the  aid  of  hooks.  The  chiselling  of  the  mastoid  process  and  the  opening  of  the 
antrum  is  entirely  free  from  pain.  In  fact  these  parts  do  not  seem  to  be  possessed  of 
marked  pain  sense.  Anesthesia  of  the  tympanic  cavity  may  be  imperfect  and  it  may 
be  necessary,  after  the  separation  of  the  membranous  canal,  to  apply  a  20  per  cent, 
alypin  or  cocain-suprarenin  solution  to  the  mucous  membrane.  The  region  of  the 
tube  nearly  always  remains  sensitive.  The  anemia  of  the  operative  field  is  of  marked 
advantage  in  this  operation,  and  makes  possible  the  previously  mentioned  plastic 
incision  at  the  beginning  of  the  operation.  The  drawback  to  this  method  of  operating 
is  the  very  unpleasant  sensation  to  the  patient  from  the  use  of  the  chisel.  If  the 
surgeon  selects  his  cases,  excluding  the  nervous  and  excitable  ones,  he  will  find 
that  the  majority  of  radical  operations  can  be  carried  out  with  perfect  satisfaction 
to  both  the  patient  and  the  operator  if  morphin  or  morphin-skopolamin  precedes 
the  anesthetic. 

The  opening  of  the  mastoid  process  and  the  antrum  under  local  anesthesia  was 
attempted  before  this  method  was  tried  for  the  radical  operation  (Reclus,  Schleich, 
Scheibe,  Thies,  Alexander,  Neumann).  Inasmuch  as  these  cases  usually  belong  to  the 
acute  septic  type,  it  is  well  to  consider  carefully  the  advisability  of  injecting  into  such 
an  operative  field.  According  to  the  author's  judgment  there  must  be  very  definite 
conditions  contra-indicating  the  use  of  general  anesthesia  before  local  anesthesia 
should  be  attempted.  At  any  rate,  this  method  of  anesthesia  will  be  used  much 
more  frequently  in  the  radical  operation  than  in  cases  of  acute  otitis.  In  })erf()rati()n 
of  phlegmonous  suppurations  these  injections  are  not  permissible. 

For  the  opening  of  the  antrum  the  Neumann  injection  is  not  necessary,  and  the 
operator  should  proceed  as  in  the  radical  operation.  For  the  simple  opening  of  the 
mastoid  cells,  infiltration  of  the  soft  parts  is  sufficient. 

Attempts  have  been  made  to  block  the  glossopharyngeal  nerve  at  the  base  of  the 
14 


210  LOCAL  ANESTHESIA  ; 

skull  by  injections  through  the  mouth,  but  without  result.    However,  Hirschel  has 
apparently  succeeded  in  blocking  the  glossopharyngeal  and  vagus  by  means  of  an  , 
injection  between  the  condyle  of  the  lower  jaw  and  the  mastoid  process.    Whether  ! 
it  will  be  possible  to  block  the  upper  branches  supphing  the  organs  of  hearing  I 
remains  to  be  seen.  | 

Blocking  of  the  Trigeminus  Nerve. — The  blocking  of  one  or  more  branches  of  the  | 
trigeminus  nerve  is  advisable  in  nearly  all  operations  upon  the  face  which  are  not  con- 
fined to  the  skin  or  subcutaneous  tissue.  The  blocking  can  be  carried  out,  according  | 
to  the  demands  of  the  operation,  either  at  the  points  of  exit  of  the  nerve  trunks  at  [ 
the  base  of  the  skull  in  the  course  of  one  or  more  of  their  branches,  or  intracranial  \ 
in  the  Gasserian  ganglion  itself.  * 

Anesthesia  of  the  trigeminus  nerve  at  the  base  of  the  skull  was  first  performed  by 
Matas  in  the  foramen  rotundum.     Bockenheimer,  at  the  suggestion  of  Payrs,  like- 
wise carried  out  this  procedure.     The  first  contribution  and  description  of  several  ; 
operations  upon  the  face  was  published  by  Peuckert.     The  method  has  since  been  ] 
materially  improved  following  the  introduction  by  Schloesser  of  alcohol  injections  I 
in  the  treatment  of  trigeminal  neuralgia,  and  by  the  work  of  Haertel.     We  are  | 
indebted    to    Offerhaus    for    his    important   communications    in   reference   to   the  ; 
techniciue  of  injection  of  the  third  branch  of  this  nerve.    He  devised  this  method 
independently,  following  his  experiments  with  alcohol  injections.    He  likewise  used 
anesthetic  substances  to  render  operations  painless. 

For  the  central  trigeminus  injection  the  long  thin  needles  Xos.  5  and  6  (page  174) 
should  be  used.     The  needleholder  as  shown  in  Fig.  14  will  be  found  very  helpful  \ 
with  needles  of  this  length.  j 

Ophthalmic  Nerve. — The  peripheral  branches  on  the  forehead  are  easily  reached  j 
by  a  subcutaneous  injection  of  5  to  10  c.c.  of  a  1  per  cent,  novocain-suprarenin 
solution   made   transversely    above  the   eyebrows.     Fig.  50  shows  the  extent  of 
the  anesthesia  following  this  injection.    The  area  of  this  anesthetic  field  is  quite 
variable  and  the  principle  as  previously  laid  down  should  always  be  followed,  that  ; 
in  operations  upon  the  forehead  and  scalp,  large  operative  fields  should  always  be  \ 
circuminjected.  j 

The  trunk  of  the  ophthalmic  nerve  cannot  be  directly  injected,  inasmuch  as  it  \ 
usually  divides  into  its  branches,  the  lacrimal,  frontal,  and  nasociliary,  before 
entering  the  orbit.  The  nasociliary  passes  through  the  annulus  tendineus  into 
the  apex  of  the  orbit  and  innervates  the  eye  (Fig.  51).  Its  two  branches,  the 
ethmoidal  nerves,  leave  the  apex  of  the  orbit  and  pass  into  the  anterior  and  posterior 
ethmoid  foramen.  The  frontal  and  lacrimal  lie  entirely  outside  of  the  apex  of 
the  orbital  wall,  and  like  the  ethmoidal  nerves  are  inaccessible  to  injections  in  the 
posterior  portion  of  the  orbit. 


OPERATIONS  ON  THE  HEAD 


211 


Tlie  walls  of  that  i)()rti()n  of  the  orbit  which  are  straiiiht  and  not  concave  are 
particularly  suitable  for  injection,  and  serve  as  a  guide  for  the  needle  to  the  orl)ital 
apex  beyond  the  muscular  covering,  keeping  the  needle  in  constant  contact  with  the 
bone.    These  conditions  are  found  along  the  lateral  walls  and  the  ujjpcr  portion  of 


Fig.  50. — Extent  of  absolute 


frontal  branches  of  the  ophthalmic  r 


Ethmoidal  |  "s'  •:;' 

Ociihir  innscles  i  ' 


Annidus  tendineus    , 


CUiary  uer 
ganglion 

Fig.  51. — Diagrammatic  course  of  the  ophthalmic  nerve.     (After  Corning.) 


the  median  wall  of  the  orbit.  In  other  places  where  the  point  of  the  needle  cannot 
be  held  in  contact  with  the  bone  there  is  always  danger  of  injury  to  the  eye-ball. 
The  use  of  curved  needles  cannot  be  recommended,  as  the  exact  location  of  the  point 
is  never  known.  The  lateral  point  of  injection  lies  immediately  above  the  outer 
canthus  of  the  eye.    The  needle  is  passed  \v\i\\  its  point  constantly  in  contact  wdth 


212 


LOCAL  ANESTHESIA 


the  bone  to  a  depth  of  4.5  to  5  cm.  and  here  crosses  the  superior  orbital  fissure 
(Fig.  52).  The  point  encounters  the  distal  border  of  this  fissure  in  the  upper  wall 
of  the  orbit  which  prevents  its  further  introduction.  About  2.5  c.c.  of  a  2  per  cent, 
novocain-suprarenin'solution  is  injected  in  the  neighborhood  of  the  superior  orbital 
fissure. 

Ten  mien  cthmoidale 
po&terioi     anUiior 


Fig.  52. — Median  and  lateral  orbital  injections. 


The  point  of  entrance  for  the  median  orbital  injection  lies  one  fingerbreadth  above 
the  inner  canthus  of  the  eye.  The  needle  is  again  passed  to  a  depth  of  4  to  5  c.c, 
keeping  it  at  all  times  in  contact  with  the  bone,  and  the  same  quantity  of  solution 
injected  at  this  point. 

The  lateral  orbital  injection  blocks  the  frontal  and  lacrimal  nerves  which  is 
necessary  in  operations  in  the  orbit  and  frontal  sinuses.  The  frontal  nerve  and  its 
branches  can  likewise  be  blocked  farther  forward  in  the  orbit  b}'  injections  made 
above  the  bulb. 

The  median  orbital  injection  blocks  the  anterior  and  posterior  ethmoidal  nerves 
which  supply  the  mucous  membrane  of  the  cribriform  plate  of  the  ethmoid,  frontal, 
and  sphenoid  sinuses.  Besides  these  parts  the  anterior  ethmoidal  nerve  supplies  a 
portion  of  the  nasal  mucous  membrane  (Figs.  79  and  SO),  and  then  passing  from  the 
nose  at  the  junction  of  the  cartilaginous  and  bony  part  is  distributed  in  the  skin 
of  the  tip  of  the  nose  and  its  surroundings  (Fig.  33).  The  median  orbital  injection 
is,  therefore,  necessary  in  operations  upon  the  nasal  cavities  and  other  accessory 
sinuses. 

After  the  injection  a  mild,  transient  protrusion  of  the  bulb  and  edema  of  the  upper 
lids  occurs.  The  injections  into  the  orbit  cause  ^'ery  little  pain  if  the  points  for  injec- 
tion are  first  made  insensitive  by  means  of  a  wheal.     The  injected  fluid  is  entirely 


OPERATIONS  ON  THE  HEAD  213 

outside  of  the  inuscular  boundaries  of  the  orbit,  for  which  reason  the  sensory  nerves 
of  the  bulb,  ciliary  nerves,  ciHary  ganglion  and  the  ()j)tic  ner\e  ar<>  not,  as  a  rule, 
afl'ected.  If  the  nerves  just  mentioned  are  to  be  anesthetized  the  solution  must  be 
injected  behind  the  bulb  and  within  the  muscle  boundaries  of  the  orbit  (see  page  232). 

Serious  disturbances  following  orbital  injections  and  injury  to  the  l)ulb  are  practi- 
cally impossible.  Small  hematomata  occur  occasionally  in  the  orbital  fat,  particularly 
following  the  lateral  injections,  but  are  of  no  consecjuence.  Kredel  observed  amaurosis 
lasting  ten  minutes  following  an  injection  into  the  orbit.  It  is  possible  that  this 
occurrence  ma>'  have  been  more  frequently  observed  than  reports  indicate,  inasmuch  as 
the  oj^tic  ner\e  can  be  affected  by  the  anestlietic  as  well  as  by  the  anemia  consequent 
upon  the  use  of  suprarenin.  Another  case  of  temporary  amaurosis  following  local 
anesthesia  for  empyema  of  the  frontal  sinuses  has  been  reported  by  Jassenetzky. 
This  condition  occurred  on  the  day  following  the  operation  and  was  due  to  an 
inflammatory  edema  of  the  orbit,  and  inasmuch  as  the  case  was  a  septic  one, 
it  is  A'ery  questionable  whether  the  injection  had  anything  to  do  with  the 
inflammatory  symptom . 

Maxillary  Nerve. — The  peripheral  branches  of  this  nerve  are  the  infraorbital, 
superior,  posterior,  and  median  alveolar  nerves.  The  latter  penetrate  the  upper  jaw 
posteriorly  to  the  maxillary  tubercle  (see  Fig.  95,  page  257).  Both  of  these  branches 
are  readily  blocked. 

The  infraorbital  foramen  can  be  reached  by  passing  a  needle  beneath  the  upper  lip 
where  the  submucosa  is  reflected  from  the  alveolar  process  along  the  anterior  surface  of 
the  upper  jaw  to  the  point  of  emergence  of  this  nerve,  or,  better,  by  passing  the  needle 
from  without  directly  into  the  infraorbital  foramen.  The  injection  after  either  method 
is  2  c.c.  of  a  2  per  cent,  novocain-suprarenin  solution.  When  passing  the  needle  from 
without  into  the  infraorbital  foramen,  a  fine  one  should  be  used  and  inserted  just 
beneath  the  lower  orbital  border  and  passed  until  it  touches  the  bone,  where  a  small 
quantity  of  a  2  per  cent,  novocain-suprarenin  solution  is  injected,  following  which  the 
opening  of  the  canal  is  sought  with  the  needle.  The  injection  of  1  c.c.  of  a  2  per  cent, 
solution  is  sufficient  for  blocking  the  nerve.  Fig.  53  shows  the  extent  of  the  anesthesia 
following  a  bilateral  injection.  The  following  structures  are  anesthetized:  the  lower 
eyelids,  the  upper  lip,  the  larger  part  of  the  alse  of  the  nose  (skin  and  mucous  mem- 
brane), a  part  of  the  skin  and  mucous  membrane  of  the  cheek,  the  labial  mucous 
membrane,  the  anterior  portion  of  the  upper  alveolar  process  and  its  periosteum,  the 
anterior  wall  of  the  upper  jaw  and  the  pulp  of  the  central  and  lateral  incisor  teeth. 

The  superior,  posterior,  and  median  alveolar  nerves  are  easily  injected  at  the  max- 
illary tubercle  either  from  the  mouth  or  from  without.  With  the  former  method  the 
needle  is  passed  beneath  the  zygoma  where  it  joins  the  superior  maxillary  bone  beneath 
the  mucous  membrane  to  the  posterior  border  of  the  upper  jaw  (see  Fig.  97).    The 


214 


LOCAL  ANESTHESIA 


method  of  directing  the  needle  from  without  will  presently  be  described  and  is  the 
same  as  used  for  injections  of  the  foramen  rotundum,  only  it  is  not  necessary  to  pass 
the  point  of  the  needle  into  the  pterygopalatine  fossa.     In  either  case  5  c.c.  of  a  1  or 


Fig.  53. — Extent  of  skin  anesthesia 
following  a  bilateral  injection  into  the 
infra-orbital  foramen. 


Fig.  .54. — Innervation  of  the  hard 
palate:  a,  ant.  palatine  nerve;  6,  point 
for  injection;  c,  nasopalatine  nerve. 
(Scarpa.) 


—Anesthetizing  the  nasal  mucous  membrane  according  to  the  method  of  Kill 
a,  point  of  injection;   b,  ethmoidal  nerve;   c,  nasopalatine  nerve. 


OPERATIOSS  OX  Till-:  HEAD 


215 


2  i)cr  cent,  novocain-suprarenin  solution  is  injected  along  the  posterior  border  of 
the  upper  jaw,  which  produces  anesthesia  of  the  pulps  of  the  molar  and  bicuspid  teeth 
and  mucous  membrane  of  the  antrum  of  Ilighmore. 

The  nerves  supplying  the  hard  palate  can  be  readily  interrupted  by  peripheral 
injections.  These  nerves  are  the  anterior  palatine  and  the  nasopalatine.  The  former 
emerges  from  the  foramen  palatinum  magnum  in  the  neighborhood  of  the  third  molar 
tt)oth,  and  the  latter  from  immediately  beliind  tlie  incisor  teeth  (Fig.  'A).    If  a  few 


Fig.  5G. — Injection  of  the  fora 


drops  of  a  2  per  cent,  novocain-suprarenin  solution  be  injected  beneath  the  co^er- 
ing  of  the  hard  palate  back  of  the  left  central  incisor,  followed  by  1  to  2  c.c.  of  the 
solution  injected  at  the  point  marked  h  (Fig.  54),  which  is  about  1  to  1.5  cm.  from 
the  gum-line  and  internal  to  the  second  molar  tooth,  anesthesia  of  the  corresponding 
half  of  the  hard  palate,  and  its  soft  parts,  the  lingual  side  of  the  gums  and  the  peri- 
osteum, will  be  obtained.  The  roots  and  pulp  of  the  teeth  in  this  neighborhood  are 
not  anesthetized  by  injections  into  these  nerves. 


216 


LOCAL  ANESTHESIA 


Killian,  by  injections  under  the  mucous  membrane  near  the  upper  border  of  the 
vomer  and  upper  border  of  the  septum  (Fig.  55),  has  attempted  to  anesthetize  the 
peripheral  branches  of  the  first  and  second  divisions  of  the  trigeminus  (ethmoidal  and 
nasopalatine). 

Matas  was  the  first  to  attempt  to  anesthetize  the  maxillary  nerve  in  the  foramen 
rotundum.  Before  the  introduction  of  suprarenin  this  was  not  possible  owing 
to  the  large  dose  of  cocain  necessary  for  a  protracted  operation.  His  method  was 
to  pass  the  needle  beneath  the  lower  border  of  the  zygoma  and  along  the  posterior 
surface  of  the  upper  jaw  into  the  pterygopalatine  fossa,  which  is  simple  and  certain. 


Fig.  57. — Injection  in  the  foranifii  rotundum  tiuni 
patient  has  a  large  root  cyst  of  the  left  lower  jaw  and  a  --ui 
is  being  made  for  operation  upon  the  latter. 


( (.1  k  guide  on  the  needle.     The 
ight  upper  jaw.    This  injection 


This  method  was  likewise  used  by  Schloesser  for  the  injection  of  alcohol.  Fig.  56 
shows  the  position  of  the  bony  parts  and  Fig.  57  the  position  of  the  needle  after  intro- 
duction through  the  face.  The  point  of  insertion  of  the  needle  lies  immediately 
behind  the  lower  palpable  angle  of  the  malar  bone  and  is  marked  by  a  wheal.  From 
this  point  the  needle  is  pressed  inward  and  upward;  its  point  passes  through  the 
masseter  muscle  and  then  comes  in  contact  with  the  superior  maxillary  tubercle 
and  is  forced  carefully  along  the  surface  of  this  bone.  The  needle-point  will  occa- 
sionally strike  the  wing  of  the  sphenoid,  in  which  case  the  direction  of  the  needle 
must  be  slightly  changed  or,  if  necessary,  withdrawn  entirely  and  another  point  of 
entrance  made  just   back  of  the  middle  of  the   zygoma.     The  needle   will   then 


J 


OI'Kh'ATIOXS  OX  TIIK  HEM)  217 

suddenly  pass  deeper  into  \\\v  ])t('ry_n()palatine  fossa  and  reach  the  ner\-es  at  a 
depth  of  5  to  G  em.  At  tlie  siinie  moment  the  ])atient  will  (•()mi)lain  of  rathating 
pain  in  the  face,  after  which  .')  c.c.  of  a  2  per  cent,  novoeain-snprarenin  solution 
is  injected,  moving  the  needle  hack  and  forth  slowly.  The  needle  is  then  par- 
tially withdrawn  and  5  c.c.  of  O.o  to  1  per  cent,  noxocain-suprarenin  solution  is 
injected  back  of  the  ui)per  jaw  to  cause  a  contraction  of  the  branches  of  the  internal 
maxillary  artery. 

The  foramen  rotundum  may  })e  reached  by  injections  through  the  orbit  (Fig.  58). 
Payr,  after  experimenting  on  the  cadaver,  advised  this  method  in  resections  of  the 
u{)per  jaw.^ 


Fig.  58. — Injection  at  the  foramen  rotundum,  tln-ough  the  orbit. 

Upon  Payr's  suggestion,  Bockenheimer  anesthetized  the  second  branch  of  the 
trigeminus  and  resected  the  same  for  neuralgia.  During  the  past  year  the  writer 
has  used  the  orbital  method  in  operations  upon  the  teeth  and  antrum  of  High- 
more,  likewise  for  alcohol  injections.  The  method  is  as  follows :  A  point  is  chosen 
for  injection  where  the  lower  edge  of  the  orbit  meets  the  outer  edge.  The  needle  is 
passed  into  the  orbit  at  this  point  in  an  almost  vertical  direction,  and  kept  in  con- 
stant contact  with  the  bone  forming  the  floor  of  the  cavity  (Fig.  59).  The  inferior 
orbital  fissure  is  now  sought  and  recognized  by  the  needle  passing  into  it.  As  soon 
as  this  happens,  the  end  of  the  needle  is  lowered  so  that  it  will  assume  a  horizontal 
position  (Fig.  60),  which  prevents  it  passing  into  the  infratemporal  fossa  or  into  the 
orbital  fat,  which  is  also  to  be  avoided.  A  false  passage  will  be  recognized  by  the 
absence  of  resistance  to  the  progress  of  the  needle.     This  resistance  always  occurs 

'  The  autlior  regrets  having  overlooked  the  reports  of  Pa.\r  and  Bock(nh(;im(>r,  wliich,  however,  do  not 
seem  to  have  been  applied  practically  to  any  extent. 


218 


LOCAL  ANESTHESIA 


when  the  proper  direction  is  taken  and  causes  immediate  radiation  of  paresthetic 
sensations  which  frequently  require  the  injection  of  a  few  drops  of  the  novocain- 


FiG.  59. — Injection  at  the  foramen  rotimdum  through  the  orbit. 


Fig.  60. — Injection  at  the  foramen  rotundum  through  the  orbit, 


suprarenin  sokition.    At  a  depth  of  about  5  cm.  the  needle  will  be  in  the  foramen 
rotundum  and  there  encounter  the  bony  obstruction  at  the  base  of  the  skull. 


OPERATIONS  ON  THE  HEAD  219 

After  :i  successful  iujectiou,  anesthesia  will  immediately  occur  in  the  entire  area 
of  distribution  of  the  maxillary  ner\e.  Injections  which  have  been  only  partially 
successful  require  ten  to  twenty  minutes  before  the  full  effect  is  obtained.  After 
these  injections  the  corresponding  half  of  the  face  becomes  anemic  in  consecj[uence  of 
tlie  action  of  the  suprarenin  on  the  end  branches  of  the  internal  maxillary  artery. 

One  of  the  secondary  efYects  which  may  follow  injection  into  the  pterygopalatine 
fossa,  besides  small  hematomata  on  the  posterior  surface  of  the  upper  jaw,  is  paralysis 
of  the  muscles  of  the  eye,  particularly  the  oculomotor  nerve,  due  to  the  needle  occa- 
sionally passing  through  the  inferior  orbital  fissure  into  the  orbit.  This  paralysis 
disappears  with  the  return  of  sensation.  Although  the  dangers  following  injections 
for  purposes  of  anesthesia  are  slight  one  must  be  particularly  careful  with  alcohol 
injections.  Alcohol  must  never  be  introduced  until  after  the  nerve  has  been  blocked 
with  anesthetics  in  order  to  prevent  these  secondary  effects  on  the  muscles  of  the  eye. 

Injection  through  the  orbit  does  not  cause  paralysis  of  the  muscles  of  the  eye, 
inasmuch  as  the  needle  passes  entirely  out  of  the  orbit,  for  which  reason  alcohol 
injections  can  be  made  much  more  safely  by  this  route.  Hematomata  on  the  floor 
of  the  orbit  and  in  the  upper  lid  occasionally  occur  after  orbital  injections. 

Mandibular  Nerve. — There  are  two  methods  of  injection  for  the  third  branch  of  the 
trigeminus,  both  of  which  are  certain  and  bring  about  a  rapid  blocking  of  the  nerve. 
The  first  consists  in  interrupting  the  inferior  alveolar  and  lingual  nerves  by  injection 
on  the  inner  surface  of  the  lower  jaw  into  the  region  of  the  lingula;  the  other  consists 
in  blocking  the  nerve  trunk  in  the  foramen  ovale. 

Descriptions  of  the  method  of  anesthetizing  the  inferior  alveolar  and  lingual  nerves 
at  the  lingula  were  given  by  Halsted  and  Raymond  (1885).  Raymond  described 
an  injection  performed  in  this  region,  using  13  drops  of  a  4  per  cent,  cocain  solution. 
After  about  seven  minutes  almost  complete  loss  of  sensation  was  observed  in  the  right 
half  of  the  tongue,  gums,  and  teeth  of  the  right  lower  jaw,  so  that  cavities  in  the  first 
molar  tooth  could  be  treated  without  pain.  After  about  twenty-eight  minutes  sensa- 
tion returned  to  normal.  Schleich  later  directed  attention  to  this  method  again.  He 
used,  however,  dilute  solutions  of  cocain  with  which  he  was  unable  to  block  the  nerve 
trunk  completely.  Efforts  were  then  made  by  dentists  to  block  the  inferior  alveolar 
nerve  at  the  lingula  (Thiesing,  Krichelsdorf,  Dill,  and  Huebner)  by  means  of  cocain- 
suprarenin  solution,  and  this  method  has  now  become  one  of  the  common  pro- 
cedures of  the  dentist.    The  technique  of  the  operation  is  as  follows: 

The  finger  is  passed  into  the  mouth  until  it  touches  the  ascending  ramus  of  the  jaw. 
At  about  1.5  cm.  lateral  to  the  third  molar  tooth  the  sharp  edge  of  the  coronoid 
process  can  be  recognized,  which  runs  downward  along  the  side  of  the  third  molar  tooth 
and  becomes  lost  in  the  oblique  line  (Fig.  61).  ^ledially  from  this  edge  there  is  a 
small,  three-cornered,  concave,  bony  area  covered  with  nuicous  membrane,  directed 


220 


LOCAL  ANESTHESIA 


Fig.   61. — Injection  at  the  lingula. 


Vestibuliim         Fluor  uf  mouth 


Bucciudtor  mii.-'cle 


Inf.  alveolar  nerve 
Int.  pterygoid  muscle 


External  pteri/iioid  muxde    Mandible 

s-section  through  the  ascending  ramus  of  the  jaw  parallel  to  the  biting  surface  of  the 
teeth  of  the  lower  jaw.     (From  a  preparation  by  the  author.) 


OPERATIONS  ON  THE  II KM)  221 

forward  and  inward,  and  toward  its  nicdiaii  sidt>  honndcd  hy  an  easily  palpated  bony- 
ridge  (Fig.  01,  a).  This  area  has  ncNcr  received  an  anatomical  name,  but  for  pur- 
poses of  description  it  can  be  called  "trigonum  retromolare."  With  the  mouth 
closed  this  area  lies  to  the  inner  side  of  the  third  molar  tooth;  with  the  mouth  open 
it  lies  laterally  to  the  upper  and  lower  teeth  and  is  easily  accessible.  The  point  of 
entrance  is  in  the  middle  of  the  "trigonum  retromolare,"  about  1  cm.  above  and  a  like 
distance  laterally  from  the  biting  surface  of  the  teeth  of  the  lower  jaw.  A  line  through 
this  point  and  the  ascending  ramus  of  the  jaw,  with  its  overlying  soft  parts,  must 
be  parallel  to  the  biting  surface  of  the  lower  molar  teeth  as  shown  in  Fig.  62.^ 

In  looking  from  above  into  the  vestibulum  oris  the  oblique  line  is  seen  on  the 
posterior  end  of  the  lower  alveolar  process  of  the  left  side.  With  the  three  last  molar 
teeth  the  tongue  is  seen  on  the  floor  of  the  mouth  toward  the  median  line.  On  the  cross- 
section  of  the  lower  jaw"  the  "trigonum  retromolare"  is  observed  in  the  anterior 
portion  of  the  vestibulum  oris.  The  lingual  nerve  lies  immediately  adjoining  its  inner 
edge,  just  under  the  mucous  membrane.  The  inferior  alveolar  nerve  is  1.5  cm.  back 
of  this  point  and  is  reached  just  after  emerging  from  its  bony  canal  above  the 
lingula,  lying  in  intimate  contact  with  the  bone.  It  is  separated  from  the  bone  a 
little  above  this  point,  while  below^  it  is  covered  by  the  lingula.  In  order  to  anesthetize 
both  nerve  trunks  proceed  in  the  following  manner:  With  the  patient  in  a  sitting 
posture  and  the  mouth  wide  open  the  operator  introduces  the  index  finger  of  the 
left  hand  and  locates  the  anterior  border  of  the  coronoid  process  and  the  "  trigonum 
retromolare."  The  syringe  and  needle  are  held  in  the  manner  shown  in  Fig.  63 
and  remain  in  this  position  during  the  entire  procedure.  The  needle  is  directed 
from  the  opposite  lateral  incisors  toward  the  point  of  injection  and  held  parallel  to 
the  biting  surface  of  the  low^er  teeth.  The  needle  is  inserted  at  the  above-men- 
tioned point  1  cm.  above  and  lateral  to  the  biting  surface  of  the  last  molar  tooth  into 
the  "trigonum  retromolare."  Immediately  under  the  thin  mucous  membrane  the 
bone  should  be  felt.  If  this  is  not  the  case,  the  point  of  the  needle  is  too  far  from  the 
median  line,  a  mistake  frequently  made  by  beginners.  In  this  case  the  needle  must 
be  directed  more  toward  the  median  line  until  the  border  a  (Fig.  61)  is  felt.  The 
needle  finally  passes  along  the  inner  surface  of  the  lower  jaw  into  the  deeper  parts. 
It  must  now  be  further  inserted  to  a  depth  of  2  to  2.5  cm.,  keeping  it  always  in  contact 
with  the  bone.  As  soon  as  the  needle  begins  to  penetrate  the  region  where  the  lingual 
nerve  lies,  5  c.c.  of  1  to  2  per  cent,  novocain-suprarenin  solution  shouhl  be  injected. 

Proceed  with  the  injection,  as  shown  in  Fig.  63,  using  long  needles,  so  that  the 
discomfort  occasioned  by  the  introduction  of  the  syringe  into  the  mouth  can  be 
avoided.     In  no  case  should  needles  be  so  short  that  they  can  be  lost  to  view  during 

'  This  line  is  horizontal  only  when  the  mouth  is  closed,  not  when  it  is  open.  These  cuts  have  been  made 
from  decalcified  bones  and  the  finished  specimens  imbedded  in  rclloidiu. 


222 


LOCAL  ANESTHESIA 


the  injection,  as  it  is  a  very  difficult  matter  to  remove  a  broken  needle  from  this 
area.  The  interruption  of  both  nerves  occurs  as  a  rule  in  a  few  minutes  and  can  be 
tested  by  the  loss  of  sensation  in  the  lower  lip,  the  tongue,  and  the  floor  of  the  mouth. 
Schloesser,  for  the  injection  of  alcohol  into  the  inferior  alveolar  nerve,  passes  a 
curved  needle  from  without  just  under  the  end  of  the  mastoid  processes  around  the 
joint  of  the  lower  jaw  to  the  lingula.^ 


Fig.  63. — Injection  at  the  lingula,  showing  the  position  of  the  syringe. 


It  is  sometimes  necessary  to  interrupt  the  end  branches  of  the  inferior  alveolar 
nerve  and  the  mental  nerve.  This  can  be  accomplished  by  the  injection  of  a  1  to  2 
per  cent,  novocain-suprarenin  solution  into  the  mental  foramen  which,  as  a  rule, 
is  below  the  space  between  the  first  and  second  bicuspid  teeth. 

The  shortest  and  most  certain  way  of  reaching  the  foramen  ovale  is  from  without, 
the  needle  being  passed  just  below  the  border  of  the  zygoma,  and  if  the  directions  of 
Offerhaus  are  followed  there  is  almost  absolute  certainty  that  the  anesthetic  solution 
will  not  only  be  injected  around  the  foramen  ovale  but  directly  into  the  trunk  of  the 
mandibular  nerve  where  it  emerges  from  the  skull. 

Offerhaus  found,  after  accurate  measurement  of  50  skulls,  that  the  line  (linea  inter- 
tubercularis  Fig.  64,  c,  d)  connecting  the  articular  tubercle  lies  just  in  front  of  the 


1  The  writer  has  had  no  experience  in  the  use  of  this  method,  and   does  not  believe  that  the  lingual 
Tve  will  be  interrupted  with  an  injection  of  this  kind. 


OPERATIONS  ON  THE  HEAD 


223 


maxillary  articulation,  and  intercepts  the  two  i)ointis  {a  and  b)  which  are  just  a  few 
millimeters  below  and,  as  a  rule,  the  same  distance  in  front  of  both  foramen  ovale. 
Inasmuch  as  the  mandibular  nerve  after  its  emergence  from  the  skull  passes  for- 
ward anil  downward,  the  intertubercular  line  crosses  these  nerve  trunks  exactly  at 
the  foramen  o^•ale. 


Fig.  64. — Skull  nicasuremcnty,  according  to  Offerhaus,  for  tin 

ovale  from  the  tuberculum  articulare. 


of  the  foramen 


Offerhaus  also  noted  that  the  distance  between  the  alveolar  processes  of  the  maxilla 
measured  from  the  outside  behind  the  last  molar  tooth  (Fig.  64,  e,  /)  corresponds 
within  a  few  millimeters  to  the  distance  between  both  foramen  ovale,  so  that  if  the 
width  of  the  alveolar  processes  is  subtracted  from  the  length  of  the  intertubercular 
line,  and  this  result  divided  by  2,  the  result  will  give  within  a  few  millimeters  the 
distance  of  points  a  and  b  from  the  articular  tubercle  of  the  same  side.    According 


224 


LOCAL  ANESTHESIA 


to  the  measurements  of  Offerhaus  the  minimum  distance  would  be  3.6  cm.  and  the 
maximum  4.7  cm.,  the  usual  distance  being  3.7  to  4.3  cm.  In  order  to  find  the  direction 
and  length  of  the  intertubercular  line  in  the  living  patient,  Offerhaus  constructed 
the  apparatus  shown  in  Fig.  65.  If  the  points  of  this  apparatus  are  placed  on 
both  articular  tubercles,  the  direction  of  the  intertubercular  line  is  indicated  by 
the  adjustable  points  of  the  instrument,  and  the  distance  between  both  tubercles 
is  measured  on  the  sliding  scale. 


The  injection  is  performed  in  the  following  manner:  On  the  side  where  the  injec- 
tion is  to  be  made,  the  articular  tubercle  is  marked  by  a  wheal,  and  the  point 
on  the  opposite  side  marked  with  a  blue  pencil.  The  distance  between  the  outer  side 
of  the  alveolar  process  of  the  maxilla  behind  the  last  molar  teeth  is  measured  with 
ordinary  compasses,  and  with  Offerhaus  compasses  the  length  of  the  intertu- 
bercular line  is  determined.     For  example,  if  these  distances  are  5  and  14  cm.,  the 


points  a  and  b  will  be  ' 


4.5  cm.  distant  from  the  point  of  insertion  of  the  needle. 


A  small  cork  placed  on  the  needle,  about  1  cm.  farther  than  the  above-mentioned 
length  will  show  how  far  the  needle  should  be  inserted  and  also  allow  for  additional 
play.  The  needle,  however,  should  never  penetrate  deeper  than  this.  The  Offerhaus 
compasses  are  again  placed  upon  the  head  and  the  needle  passed  into  the  tissues 
in  the  direction  indicated  by  the  points  on  the  compasses.  The  direction  of  the  needle 
is  indicated  in  Fig.  66,  needle  1.    Exactly  at  the  point  determined,  the  patient  will 


OPEJxWTIOXS  OX  THE  HEAD 


225 


coiiipliiiu  of  riuliatinu'  ])aiiis  in  the  lower  jaw.  As  a  vui 
nerve  trunk  can  l)e  ich  at  the  nee(lle-])oint,  and  at  tini 
into  this  trunk.  After  the  needle  is  in  the  ner\e  trunk 
cent.  novocain-sui)rarenin   solution  are  suffieient;  if   ne 


,  tlu>  resistance  of  the  thick 
•s  the  needle  can  be  pushed 
a  very  few  drops  of  a  2  per 
ir  the  nerve  trunk  5  c.c.  of 


this  same  solution  are  injected.     The  blocking  of  tlu>  nerve  often  occurs  instanta- 
neously, but  never  requires  more  than  five  to  ten  minutes. 


Fig.  66. — Guidance  of  the  needle  for  injection  at  the  forame 
2,  according  to  Braun. 


1,  according  to  Offcrhaus; 


The  following  description  of  the  injection  of  the  foramen  ovale  is  somewhat  simpler 
than  the  above:  The  point  of  entrance  for  the  needle  is  marked  just  below  the  middle 
of  the  zygoma  (Fig.  66,  2),  and  the  needle  inserted  in  an  almost  transverse  direction. 
This  direction  is  easily  determined  Ijy  holding  a  skull  with  the  direction  marked  by 
a  sound  along  side  the  head  of  the  patient.  At  a  depth  of  4  to  5  cm.  the  end  of  the 
needle  touches  the  bone,  the  pterygoid  process  (Fig.  66).  In  this  injection  the 
needle  is  about  1  cm.  distant  from  the  foramen  o^•ale.  This  distance  is  marked  on 
the  needle  with  the  movable  piece  of  cork.  The  needle  is  then  withdrawn  as  far  as 
15 


226  LOCAL  ANESTHESIA 

the  subcutaneous  connective  tissue,  and  is  passed  back  again  at  a  slight  angle  to  the 
same  depth  and  possibly  a  few  millimeters  more.  The  characteristic  radiating  pains 
will  then  occur. 

This  last  method  can  be  further  simplified  by  computing  the  depth  at  which  the 
foramen  ovale  is  found.  As  a  rule  the  author  combines  both  methods  in  directing 
the  needle,  but  passes  it  somewhat  more  anteriorly  than  Offerhaus,  feeling  for  the 
base  of  the  pterygoid  process.  Then,  as  already  mentioned,  the  needle  is  directed 
slightly  backward  and  inserted  0.5  to  1  cm.  more  than  the  previously  computed  dis- 
tance. Hematomata  or  other  secondary  effects  never  follow  injections  into  the 
foramen  ovale  when  made  from  without. 

The  methods  described  by  Ostwalt  and  Schloesser  for  the  injection  of  alcohol  into 
the  foramen  ovale  cannot  be  compared  with  the  method  just  described  for  certainty 
and  freedom  from  danger.  In  this  method  Ostwalt  passes  a  long  angular  needle 
through  the  wide-open  mouth  behind  the  last  molar  tooth  through  the  external 
pterygoid  muscle,  and,  by  using  the  external  lamina  of  the  pterygoid  process  as 
a  guide,  reaches  the  foramen  ovale.  Schloesser  for  like  purposes  locates  with  the 
finger  in  the  mouth  the  lower  end  of  the  wing  of  the  sphenoid,  passing  a  long 
straight  needle  through  the  cheek,  coming  out  just  below  the  finger  in  the  mouth, 
and  then  through  the  mucous  membrane  and  under  the  finger  toward  the  wing  of 
the  sphenoid  above,  until  the  resistance  of  the  base  of  the  skull  is  felt.  The  needle- 
point must  now  lie  a  few  millimeters  in  front  of  the  foramen  ovale. 

Haertel  has  described  a  very  exact  method  for  directing  the  needle  in  puncture  of 
the  Gasserian  ganglion,  which  is  in  part  similar  to  Schloesser's.  His  method  is 
likewise  of  great  \n\ue  in  the  interruption  of  the  third  branch  of  the  trigeminus. 

Puncture  of  the  Gasserian  Ganglion. — Frequently  after  the  injection  of  anesthetic 
solutions,  and  almost  regularly  after  alcohol  injections  into  the  trunk  of  the  man- 
dibular nerve  in  the  foramen  ovale,  sensory  paralysis  takes  place  not  only  in  the 
second  branch  of  the  trigeminus  but  the  first  is  also  affected.  This  can  only  be 
explained  by  the  theory  that  the  fluid  injected  into  the  nerve  trunk  is  disseminated 
into  the  Gasserian  ganglion. 

HaerteP  completed  experiments  begun  by  Schloesser,  Ostwalt,  Harris,  and  Offer- 
haus for  the  passing  of  the  needle  into  the  foramen  ovale  and  Gasserian  ganglion. 

It  is  necessary  in  this  technique  to  pass  the  needle  as  nearly  parallel  to  the  course 
of  the  mandibular  nerve  as  possible.  This  has  already  been  mentioned  by  Ostwalt 
and  Schloesser,  but  Haertel  avoids  the  possibility  of  infection  by  not  passing  the 
needle  into  the  mouth. 

1  Dr.  Haertel  was  kind  enough  to  loan  the  illustrations  shown  in  Figs.  65  to  67.  The  writer  unfor- 
tunatelj'  has  not  been  able  to  describe  in  detail  at  this  time  the  results  in  connection  with  his  work  on  the 
puncture  of  the  trigeminus  trunk  and  the  Gasserian  ganglion. 


OPERATIONS  ON  THE  HEAD 


227 


Fig.  07  shows  the  position  of  the  needle  in  the  skuH.  A  Xo.  (i  needle  !)  to  10  ein. 
in  length  shonld  be  used.  About  3  em.  lateral  to  the  eorner  of  the  mouth  a  wheal 
about  the  size  of  a  dollar  is  injeeted,  so  that  the  puncture  can  be  changed  in  case  of 
necessity  without  causing  pain.  With  the  finger  in  the  mouth  as  a  guide,  the  needle 
is  now  passed  from  the  above-mentioned  point  beneath  the  mucous  membrane  of 
the  mouth,  then  upward  between  the  ascending  ramus  of  the  jaw  and  the  maxillary 
tubercle  until  the  point  reaches  the  smooth,  hard  infratemporal  surface  just  in  front 
of  the  foramen  ovale.    The  operator  feels  with  the  end  of  the  needle,  observing  the 


.  67. — Puncture  of  the  Classeiian  iiaiiKl 


the  skull. 


following  points:  the  position  of  the  opposite  Gasserian  ganglion,  the  long  axis  of 
the  orbit,  and  the  line  connecting  the  articular  tubercle  of  the  zygoma.  If  the 
patient  is  viewed  from  the  front,  the  needle  should  lie  in  a  plane  intersecting  the  pupil 
of  the  eye  of  the  same  side  (Fig.  G8).  Viewed  from  the  side  the  needle  should  lie  in 
a  plane  intersecting  the  articular  tubercle  (Fig.  69). 

It  is  very  essential  to  locate  the  infratemporal  plane  so  that  the  needle  will  not 
be  passed  behind  the  foramen  ovale.  To  guard  against  this  it  is  best  to  pass  the  needle 
in  the  plane  intersecting  the  pupil,  as  shown  in  Fig.  68,  sharply  upward  so  that  when 


228 


LOCAL  ANESTHESIA 


Fig.  69. — Puncture  of  the  Gasserian  ganglion,  viewed  from  the 


OPERATIONS  ON  THE  HEAD 


229 


viewed  from  the  side  the  ])laiie  of  the  needle  instead  of  interseeting  the  articuhir 
tuberele  intercepts  the  middle  of  the  zygoma.  The  Inih  of  the  needle  is  then  gradually 
raised,  keeping  it  ahvays  in  the  i)lane  of  the  pupil,  until  the  point  of  the  needle  passes 
behind  the  infratemporal  i)lane.  These  manipulations  become  clear  if  they  are 
carried  out  on  the  cada\'er,  with  a  skull  alongside  as  a  guifle.  Fig.  70  shows  a  patient 
with  the  needle  in  the  ganglion.  Radiating  sensations  in  the  lower  jaw  is  evidence 
that  the  mandibular  nerve  is  located.  The  distance  from  the  point  of  entrance  to  the 
foramen  ovale  is  5  to  7  cm.  The  needle  is  inserted  for  1  to  1  .o  em.  farther  in  the  same 
direction  until  the  jxitient  eonii)lains  of  paresthesia  in  the  ui)i)er  jaw. 


ion  preparatory  to  the  injcc 


The  foramen  ovale  can  he  reached  objectively,  independent  of  any  statement 
from  the  patient,  and  its  position  readily  determined  from  the  manner  in  which  the 
needle  suddenly  passes  into  the  depths  behind  the  infratemporal  plane.  The 
(iasserian  ganglion  can,  therefore,  be  punctured  under  general  anesthesia,  which  is 
of  the  utmost  importance  in  the  treatment  of  very  severe  trigeminal  neuralgia.  As 
soon  as  the  needle  is  properly  placed,  0.5  to  1  cm.  of  a  2  per  cent,  novocain-suprarenin 
solution  is  injected.  Nerve  blocking  occurs  immediately  in  all  three  branches  of  the 
trigeminus  and  lasts  from  one  to  three  hours.  The  injection  is  frequently  accom- 
panied by  vomiting  and  attacks  of  vertigo,  particularly  if  more  solution  is  injected 
than  mentioned  above.  The  technique  is  not  at  all  difHcult  after  a  little  practice, 
unless  the  configuration  of  the  skull  is  abnormal.     Whether  the  metht)d  of  intra- 


230  LOCAL  ANESTHESIA 

cranial  injection  is  quite  free  from  danger  remains  to  be  seen.  It  is  suitable  in  the 
revolutionary  treatment  of  trigeminal  neuralgia  as  introduced  by  Schloesser,  but 
it  is  impossible  at  this  time  to  give  full  details. 


OPERATIONS   IN   THE   ORBIT.      EYE    OPERATIONS. 

General  anesthesia  as  used  in  ophthalmology  is  always  attended  by  certain  serious 
disadvantages  which  at  the  present  time  have  happily  been  overcome  by  the  intro- 
duction of  local  anesthesia. 

One  of  the  most  important  of  these  disadvantages  lies  in  the  fact  that  general 
anesthesia  of  the  eye  must  be  very  deep  to  be  effective,  much  deeper  than  in  opera- 
tions upon  other  parts  of  the  body  because  of  the  well-known  fact  that  sensation  of 
the  eye  is  the  last  to  disappear.  With  this  necessary  increase  in  depth  the  danger  of 
general  anesthesia  is  proportionately  increased,  due  to  necessary  interruptions  on 
account  of  respiratory  difficulties  or  vomiting.  These  interruptions  are  so  dangerous 
that  certain  eye  operations  if  undertaken  might  result  seriously.  Then  again,  under 
general  anesthesia  motion  in  the  eye  ceases,  a  distinct  disadvantage  in  some  opera- 
tions. So  it  happens  that  local  anesthesia  has  proved  to  be  the  most  important 
anesthetic  procedure  in  ophthalmology,  and  is  used  in  the  majority  of  all  eye  operations 
today. 

Ophthalmologists  use  local  anesthesia  partly  as  an  instillation  and  partly  as  sub- 
conjunctival and  subcutaneous  injections.  The  conjunctival  sac  is  a  particularly 
suitable  place  for  the  superficial  application  of  anesthetic  agents,  because  when  the 
eye  is  closed  it  forms  a  closed  sac  which  holds  the  instilled  anesthetic  for  a  consider- 
able time  and  spreads  it  over  tissues  which  have  a  high  power  of  absorption.  For 
this  reason  it  is  easy  to  bring  large  quantities  of  an  anesthetic  substance  in  contact 
with  the  cornea  and  conjunctiva,  much  more  than  in  applications  to  the  nose  and 
larynx,  as  in  the  latter  case  the  drug  is  in  contact  with  the  mucous  membrane  for 
only  a  short  time.  For  the  same  reason  anesthesia  of  the  eye  is  not  confined  to  the 
surface  but  penetrates  the  cornea  and  the  fluid  contents  of  the  anterior  chamber, 
even  at  times  affecting  the  bulb  to  a  greater  or  less  extent.  Dilute  solutions  can  be 
used  in  the  eye  very  advantageously  for  local  anesthesia  owing  to  its  structure.  All 
substitutes  for  cocain  are  tested  by  preference  in  the  eye.  It  is  a  very  sensitive  organ 
and,  therefore,  a  particularly  advantageous  field  for  testing  new  substances  as  to 
their  anesthetic  action  as  well  as  their  irritating  properties. 

Cocain  has  never  been  displaced  from  its  dominant  position  in  ophthalmology  by 
any  of  the  newer  drugs.  For  its  early  practical  use  in  eye  operations  see  Chapter 
MI.    Almost  all  the  new  substitutes  cause  more  or  less  irritation  upon  instillation 


OPERATIONS  ON  TllK  1 1  KM)  231 

into  the  c'Ollj^llK■ti^■al  sac.  /J-cvicain,  tropacocain,  and  liolocaiii  arc  the  only  substi- 
tutes wliicli  have  found  any  advocates  among  the  Aarious  substitutes.  Ilolocain, 
ho^ve^•o^,  o^^  ing  to  its  marked  toxic  properties,  has  only  been  used  for  very  superficial 
anesthesia.  Tropacocain  (3  to  5  per  cent.)  and  holocain  (1  per  cent.)  have  been 
highly-  valued  as  anesthetic  substitutes,  owing  to  the  fact  that  they  do  not  irritate, 
their  action  is  rapid  and  profound,  and,  in  contrast  to  cocain,  cause  neither  paralysis 
of  the  pupil  and  accommodation  nor  any  change  in  ocnlar  tension.  Recently  novocain 
and  alypin  have  found  considerable  support  in  the  profession.  Reichmuth  still 
holds  that  cocain  is  the  best  anesthetic  for  the  ophthalmologist,  inasmuch  as  it 
causes  the  least  injury  to  the  eye,  and  for  this  reason  the  majority  of  ophthalmolo- 
gists have  remained  true  to  it.  As  the  instillation  of  fairly  concentrated  cocain 
solutions  is  not  likely  to  cause  toxic  symptoms,  there  is  no  reason  why  this  remedy 
should  be  supplanted  by  any  other.  For  all  injections,  however,  novocain  is  to  be 
preferred.  Ophthalmologists  were  likewise  the  first  to  recognize  the  effect  of  supra- 
renin  upon  the  action  of  cocain  (see  Chapter  VIII). 

Anesthesia  of  the  Eye  by  Instillation. — Instillations  of  2  to  5  per  cent,  cocain  solu- 
tions are  used,  and  the  activity  of  the  drug  can  be  markedly  increased  by  the  addi- 
tion of  suprarenin.  For  superficial  operations  upon  the  conjunctiva  and  cornea  a 
single  instillation  is,  as  a  rule,  sufficient.  The  results  following  its  use  are  as  follows: 
The  space  between  the  lids  increases,  giving  rise  to  an  apparent  protrusion  of  the 
bulb,  the  pupil  is  enlarged,  and  the  accommodation,  depending  upon  the  dosage,  is 
more  or  less  affected.  The  conjunctiva  and  cornea  become  completely  anesthetic 
to  touch  as  well  as  to  the  action  of  heat  or  cold.  The  blood  supply  of  the  conjunctiva 
becomes  also  markedly  diminished.  Anesthesia  following  the  use  of  strong  solutions 
which  have  been  repeated  frequently  is  very  prompt  in  normal  eyes,  and  its  dura- 
tion is  of  variable  length.  The  instillation  of  a  2  per  cent,  cocain  solution  into  the 
eye  produces  anesthesia  in  about  two  minutes  and  continues  from  seven  to  ten  min- 
utes, after  which  time  sensation  gradually  returns.  In  the  older  literature  much  is 
said  regarding  the  injurious  action  of  cocain  upon  the  eye.  The  conjunctival  irrita- 
tion is  often  due  to  contamination  of  the  solution  by  acids  or  strong  antiseptics, 
particularly  sublimate,  whereas  the  affection  of  the  cornea  is  due  in  large  part  to 
the  non-observance  of  certain  precautionary  rules  regarding  the  use  of  cocain. 
Owing  to  the  increase  in  the  space  between  the  lids  and  the  absence  of  winking,  due 
to  the  action  of  cocain,  the  cornea  may  become  dry,  the  degree  depending  upon  the 
duration  of  the  anesthesia,  and  thus  occasion  cloudiness  or  casting  off  of  the  epithelium 
to  a  varying  extent.  It  may  even  cause  infection  with  the  formation  of  ulcers.  It  is 
probable  that  some  of  these  injuries  to  the  cornea  are  due  to  the  improper  use  of 
antiseptic  substances.  The  injurious  results  of  drying  can  easily  be  avoided  during 
operation  if  the  operator  or  an  assistant  closes  the  eye  frequently,  or  keeps  it  moist 


232  LOCAL  ANESTHESIA 

by  the  application  of  compresses  (Czermak).  The  mydriatic  action  of  cocain  can 
Hkewise  be  avoided  by  the  addition  of  miotic  drugs  to  the  instilled  solution. 

Following  a  single  instillation  of  cocain  into  the  eye  the  anesthesia  is  limited 
to  the  surface,  whereas,  if  a  5  per  cent,  solution  is  instilled  every  three  minutes  for 
half  an  hour,  the  iris  will,  as  a  rule,  become  insensitive.  The  operations  which  can 
be  performed  upon  the  eye  following  the  instillation  of  cocain  are  superficial  opera- 
tions on  the  conjunctiva,  removal  of  foreign  body  from  conjunctiva  and  cornea, 
cauterization  of  corneal  ulcers,  plastic  operations  on  the  cornea,  cataract  operations, 
and  operations  upon  the  lens  and  iris. 

Subconjunctival  Injections. — Subconjuncti\-al  injections  are  made,  as  a  rule,  after 
the  conjvmctiva  has  been  rendered  insensitive  in  the  usual  manner.  The  injection 
method  is  used  in  anesthetizing  the  iris  in  operations  for  glaucoma  in  which  the 
instillation  method  is  not  sufficient,  and  in  strabismus  operations.  As  a  rule,  rather 
concentrated  solutions  are  used  (3  to  5  per  cent.).  These  solutions  are  not  free  from 
toxic  action,  but,  nevertheless,  poisoning  in  ophthalmology  very  seldom  takes  place. 
Schwarz  recommends  a  2  per  cent,  solution  of  cocain  with  the  addition  of  1  to  5000 
to  1  to  10,000  suprarenin  in  operations  that  require  anesthesia  of  the  entire  iris, 
such  as  the  separation  of  numerous  synechia.  The  solution  must  be  circularly  injected 
without  interruption  beneath  the  conjunctiva  around  the  entire  cornea. 

The  anesthetic  action  takes  place  after  about  five  minutes.  Haab  suggested  for 
similar  purposes  the  placing  of  cocain  crystals  in  the  anterior  chamber  of  the  eye 
so  that  direct  action  could  be  produced  upon  the  iris.  These  crystals  are  obtained 
by  evaporating  alcoholic  solutions  of  cocain.  Others  have  suggested  the  injection 
of  anesthetic  solutions  into  the  anterior  chamber.  In  operations  for  strabismus  the 
anesthetic  solution  is  injected  at  the  point  where  the  conjunctiva  is  to  be  opened  for 
the  purpose  of  reaching  the  necessary  tendon;  the  solution  is  spread  throughout  the 
tissues  by  gentle  massage  applied  to  the  lid,  after  which  anesthesia  occurs  in  about 
five  minutes. 

Innervation  of  the  Orbit. — The  orbit  and  globe  are  innervated  by  the  ophthalmic 
nerve;  its  course  in  the  orbit  has  already  been  described  on  page  241,  Fig.  51.  Besides 
this  nerve  the  zygomatic  branch  of  the  maxillary  nerve  passes  through  the  orbital 
cavity  and  is  distributed  to  the  skin  of  the  temporal  and  zygomatic  region,  and  also 
to  the  outer  canthus  of  the  eye. 

Exenteration  of  the  Orbit. — An  injection  of  10  c.c.  of  a  1  per  cent,  novocain-supra- 
renin  solution  can  be  made  without  danger  in  the  deepest  portion  of  the  orbit  behind 
the  bulb.  Long  needles  and  the  median  and  lateral  orbital  injections  are  used  (see 
page  212).  These  injections  in  connection  with  an  additional  one  into  the  foramen 
rotundum  (see  page  216)  will  induce  complete  anesthesia  of  the  entire  orbital  cavity 
with  its  contents  and  also  the  eyelids.     The  author  has  repeatedly  performed  this 


OPERATIONS  ON  THE  HEAD  233 

operation  in  connection  with  resections  of  the  upper  jaw;  solutions  injected  in  this 
way  block  the  oj^tic  ncr\c.  Anesthesia  of  the  same  extent  can  be  produced  by  injec- 
tions into  the  (iasscrian  uan.uiion  acconHiii;-  to  Haertel's  method. 

Enucleation  and  Exenteration  of  the  Eye-ball. — Schleich  has  reported  enucleation 
of  the  eye  by  injections  of  his  cocain  solution,  but  has  not  given  definite  details 
as  to  the  technique.  Weiss  later  used  the  Schleich  method  in  5  cases  in  3  cases  he 
used  Schleich  solution  No.  3,  with  0.01  per  cent,  of  cocain,  and  in  2  cases  0.2  per 
cent,  cocain.  After  cocainizing  the  conjunctiva  with  a  2  per  cent,  solution  he  rendered 
the  ocular  conjunctiva  markedly  chemotic  by  the  injection  of  Schleich's  solution, 
after  which  he  pushed  the  needle  carefully  into  the  axis  of  the  orbit  to  both  the  nasal 
and  temporal  side  of  the  bulb  and  infiltrated  the  deeper  parts  of  the  orbital  cavity. 
The  operations  were  not  entirely  free  from  pain,  particularly  in  those  cases  where 
long-continued  inflammation  had  previously  existed.  This  same  observation  was 
made  by  Meyers.  For  the  certain  blocking  of  the  ciliary  nerves  Schleich's  solution 
is  just  as  unsuitable  as  it  has  proved  to  be  in  blocking  nerves  in  other  parts  of  the 
body.  Further  reports  regarding  enucleation  have  been  made  by  Hackenbruch.  After 
the  cocainization  of  the  conjunctiva  and  cornea  he  injected  a  0.5  per  cent,  solution 
of  eucain  and  the  same  percentage  of  cocain  circularly  behind  the  bulb,  after  which 
a  glaucomatous  eye  became  painless  and  could  be  readily  enucleated.  Haab  used 
the  same  cocain  and  eucain  solution  but  limited  its  application  to  those  cases  in 
which  inflammation  was  absent;  he  was  thus  able  to  operate  without  pain.  He 
injected  the  solutions  first  above  the  attachments  of  the  eye  muscles  and  after  separa- 
ting them  injected  large  quantities  behind  the  globe  with  curved  needles.  In  about 
five  minutes  anesthesia  occurred.  If  the  capsule  of  Tenon  remains  intact,  the  entire 
bulb  can  be  made  insensitive  by  filling  this  space  with  an  anesthetic  solution,  but  in 
diseased  conditions  of  the  eye  adhesions  frequently  take  place  between  the  bulb  and 
this  fascia,  for  which  reason  results  are  often  imperfect.  In  recent  years,  since  the  intro- 
duction of  suprarenin,  ophthalmologists  have  been  using  injection  anesthesia  more  and 
more  frequently  for  enucleations  and  exenterations  of  the  orbit.  The  method  con- 
sists in  infiltration  of  the  orbit  following  a  cocainization  of  the  conjunctival  sac. 

Loewenstein  passes  a  straight  needle  through  the  lateral  commissure  of  the  lid 
slightly  below  its  centre.  The  needle  is  then  directed  more  toward  the  median  line 
until  its  point  reaches  a  depth  of  4.5  c.c,  which  brings  it  in  the  neighborhood  of  the 
optic  nerve  and  ciliary  ganglion.  In  this  position  1  cm.  of  a  1  per  cent,  cocain  solu- 
tion with  the  addition  of  suprarenin  is  injected.  The  bulb  is  also  circularly  injected 
beneath  the  conjunctiva  with  0.5  c.c.  of  the  same  solution.  In  24  out  of  20  cases  the 
bulb  was  made  anesthetic. 

Mende  reports  the  results  obtained  by  Siegrist  with  reference  to  his  previous  work. 
He  recommends  the  use  of  a  slightly  curved  needle  which  is  introduced  from  the 


234  LOCAL  ANESTHESIA 

temporal  and  nasal  side  back  of  the  bulb  to  the  points  of  entrance  of  the  optic  and 
ciliary  nerves,  injecting  at  each  point  2  c.c.  of  a  0.5  per  cent,  novocain  solution  with 
the  addition  of  suprarenin.  Subconjunctival  injections  of  1  c.c.  of  the  same  solution 
are  made  in  the  region  of  the  attachments  of  the  recti  muscles.  From  1906  to  1910 
155  exenterations  and  enucleations  were  performed  under  local  anesthesia  and  61 
under  general  anesthesia.  The  patients  were  given  sedatives  and  narcotics  before 
the  operation.  In  the  155  cases  anesthesia  was  insufficient  in  8  cases  owing  to  improper 
technique  and  lack  of  observance  of  the  proper  indications.  Local  anesthesia  is 
contra-indicated  in  excitable  patients,  in  severe  injuries  of  the  globe,  and  purulent 
conjunctivitis  and  perforating  panophthalmitis,  whereas  irritation  of  the  eye  has 
no  effect  on  the  results  of  this  method. 

Seidel,  who  was  not  always  satisfied  with  the  method  of  Siegrist,  injected  1  to  2 
c.c.  of  a  novocain-suprarenin  solution  beneath  the  conjunctiva  around  the  bulb. 
He  then  injected  the  connective  tissues  behind  the  bulb  from  4  points  with  a  straight 
needle  passed  through  the  conjunctiva  to  the  middle  of  a  line  connecting  the  optic 
foramen  and  the  point  of  entrance  of  the  optic  nerve  into  the  bulb.  During  the  in- 
sertion of  the  needle  1  c.c.  of  this  solution  was  injected  retrobulbar.  The  operation 
w^as  begun  twenty  minutes  after  the  injection.^ 


.sthef>ia  of  the  upper  eyelid. 


Kroenlein's  Operation. — The  outer  orbital  wall  is  innervated  by  the  first  two 
branches  of  the  trigeminus  so  that  in  temporary  resections  an  interruption  of  these 
trunks  will  render  the  operation  easy.  The  first  Kroenlein  operation  under  local 
anesthesia  was  performed  by  Haertel  for  the  removal  of  a  tumor  of  the  posterior  and 

^  The  author  has  never  had  any  personal  experience  with  operations  carried  out  in  this  way,  but  believes 
it  would  be  more  convenient  to  inject  back  of  the  bulb,  from  the  orbital  border,  than  from  the  con- 
junctiva, as  has  already  been  described  in  operations  for  exenteration  of  the  orbit. 


OPERATIONS  ON   THE  HEAD  235 

median  i)orti()n  of  the  ()rl)it  which  had  invaded  the  nasal  cavity.    lie  injected  the 
Gasserian  ganghon  for  this  purjxKse. 

Operations  upon  the  Eyelids  and  Tear-sac. — Operations  confined  to  the  eyelids 
rcqnire  neither  central  orbital  injections  nor  blocking  of  the  second  branch  of  the 
trigeminus.  To  render  the  upper  lid  insensitive  a  point  of  injection  is  marked  in  the 
centre  of  the  upper  orbital  ridge  and  3  to  5  c.c.  of  a  1  per  cent,  novocain-suprarenin 
solution  injected  along  the  bony  orbital  edge  (Fig.  71).  The  anesthesia  will  also 
include  the  conjunctiva;  the  same  procedure  can  be  carried  out  on  the  lower  lid.  In 
the  latter,  injections  into  the  infra-orbital  foramen  can  also  be  used  (see  page  214). 
The  entire  cheek  is  thus  made  insensitive  at  the  same  time.  It  should  also  be  re- 
membered that  the  median  end  of  the  lower  lid  is  innervated  by  the  infratrochlear 
nerve.  The  latter  can  be  reached  by  passing  the  needle  above  the  median  to  the 
inner  canthus  and  injecting  2  c.c.  of  a  2  per  cent,  novocain-suprarenin  solution 
toward  the  median  orbital  wall.  By  this  injection  the  infratemporal  nerve  supply- 
ing the  tear-sac  will  also  be  rendered  insensitive. 


OPERATIONS   UPON    THE    SOFT   PARTS    OF    THE    FACE. 

The  extent  of  the  innervation  of  the  face  from  the  three  branches  of  the  trigeminus 
and  their  overlapping  fibers,  which  is  very  variable,  will  be  seen  in  Fig.  72.  The 
blocking  of  the  third  branch  of  the  trigeminus  at  the  foramen  ovale  produces  com- 
plete anesthesia  of  the  face,  excepting  a  small  area  of  variable  size  on  the  lower  lip 
which  is  due  to  an  overlapping  of  the  cervical  nerves.  The  blocking  of  the  second 
branch  of  the  trigeminus  produces  an  anesthetic  area  of  the  face  not  much  larger 
than  that  following  injections  into  the  infraorbital  foramen  (see  page  214). 

The  skin  of  the  nose  is  innervated  by  the  second  branch  of  the  trigeminus  and  to  a 
greater  or  lesser  extent  by  the  end  branches  of  the  ethmoidal  nerves  derived  from  the 
first  branch  of  the  trigeminus.  This  applies  particularly  to  the  tip  and  alte  of  the  nose 
(see  Fig.  33,  page  195).  The  central  blocking  of  the  trigeminal  branches  is  of  much 
importance  in  anesthesia  of  the  cavities  of  the  face,  but  the  soft  parts,  owing  to  the 
overlapping  of  the  neighboring  nerves,  and  those  from  the  opposite  side,  must  be 
circuminjected  to  produce  anesthesia.  The  typical  form  of  these  circuminjections 
has  already  been  described  in  connection  with  operations  upon  the  jaw.  The  anemia 
obtained  from  this  injection  is  of  the  greatest  importance.  Only  the  blocking  of  all 
three  branches  of  the  trigeminus  by  injection  into  the  ganglion  will  cause  extensive 
anesthesia  of  the  face.  Even  then,  areas  near  the  midline  must  be  injected  unless 
the  Gasserian  ganglion  is  blocked  on  both  sides.  In  superficial  operations  upon  the 
soft  parts  of  the  face,  central  injections  at  the  base  of  the  skull  are,  as  a  rule,  not 
necessary;  circuminjection  of  the  part  is  usually  sufficient. 


236 


LOCAL  ANESTHESIA 


Anesthesia  of  the  Exterior  of  the  Nose,  Upper  Lip,  and  Cheek. — As  an  example  of 
operations  upon  the  nope  we  will  describe  the  removal  of  a  rhinophyma  (Fig.  73). 
As  a  rule,  three  points  of  entrance  for  the  needle  are  necessary,  one  on  either  side  of 
the  alse  of  the  nose,  the  third  upon  the  bridge  at  the  bony  and  cartilaginous  junction. 
From  the  two  former  points  0.5  per  cent,  novocain-suprarenin  solution  is  freely 
injected  subcutaneously  along  the  border  of  the  pyriform  aperture  as  far  as  the 
bridge  of  the  nose.  This  injection  must  sometimes  be  supplemented  by  injections 
from  wheals  on  the  bridge  of  the  nose.     Injection  is  then  made  beneath  the  attach- 


-Inncrvation  of  the  face  and  scalp.     (Corning.)     Black  dotting,  R.  I  N.  Trigemini; 
red  shading,  R.  II  N.  Trigemini;  black  shading,  R.  Ill  N.  Trigemini. 


ment  of  the  alse  and  frenulum  to  the  upper  lip,  and  require  20  to  25  cm.  of  the  solu- 
tion. Following  this  injection  the  tip  and  alse  of  the  nose,  including  cartilage,  mucous 
membrane  and  frenulum,  will  be  rendered  insensitive.  This  operation  for  rhino- 
phyma and  the  excisions  of  areas  of  lupus  will  be  found  of  definite  advantage  owing 
to  the  anemia  of  the  operati^'e  field.  In  case  the  upper  lip  is  to  be  included  in  the 
anesthetic  field,  injections  of  10  c.c.  of  a  0.5  per  cent,  no^'ocain-suprarenin  solution 
are  made  from  points  1  and  2  in  two  lines  subcutaneously  and  submucously  to  the 
angle  of  the  mouth,  the  needle  being  guided  by  the  finger  in  the  mouth  (Fig.  74). 


orEh'ATioxs  ox  rill':  head 


237 


A  still  larger  anesthetic  field  will  be  noted  in  Fig.  75.  Besides  circuminjecting  from 
points  1-5-3-6-2,  it  is  necessary  to  inject  a  line  to  either  side  from  point  4  so  as  to 
from  points  5  and  6.  The  lines  of  injection,  1-5,  2-(),  are  made  from  points  5  and  G, 
exclude  the  etlmioidal  nerves,  as  well  as  an  injection  into  the  infra-orbital  foramen 
guiding  the  needle  by  the  finger  under  the  lip,  as  shown  in  Figs.  74  and  75. 


Fig.   73. — (iieuniinjection  of  the  nose  for  rhinophyma. 


74. — Anesthesia  of  the  outer  parts  of 
the  nose  and  upper  lip. 


-Aiic-tlie.Ma  of  the  outer  pai 
lin-c.  upper  lip,  and  cheek. 


Hare-lip  operations  are  regularly  performed  without  geueral  anesthesia.  The 
upper  lip  is  injected  on  both  sides  in  a  line  from  the  angle  of  the  mouth  to  the  aUe 
of  the  nose,  using  2.5  c.c.  of  a  0.5  per  cent.  nov()cain-s'.i])rarenin  solution  on  either 


238 


LOCAL  ANESTHESIA 


side.  The  anterior  surface  of  the  upper  jaw  is  also  injected  as  far  as  the  infra-orbital 
foramen.  Injections  are  then  made  beneath  the  alse  of  the  nose,  in  single  hare-lip 
on  one  side,  and  in  double  hare-lip  on  both  sides,  using  5  c.c.  of  the  same  solution. 
The  injections  control  the  hemorrhage;  children,  as  a  rule,  sleep  during  the  entire 
operation.  Splitting  the  cheek,  as  a  preliminary  to  operations  in  the  mouth,  is 
accomplished  by  simple  infiltration  of  the  proposed  line  of  incision.  For  this  a  single 
point  of  injection  at  the  anterior  border  of  the  masseter  muscle  is  sufficient  (Fig.  76). 
With  the  index  finger  in  the  mouth  as  a  guide  the  proposed  line  of  incision  is  injected 
with  long  needles  under  the  skin  and  mucous  membrane  as  far  as  the  angle  of  the 
mouth. 


Fig.  76. — Injoi 


verse  cutting  of  the  cheek. 


Operations  upon  the  Lower  Lip  and  Region  of  the  Chin. — For  operations  limited 
to  the  lower  lip,  a  wedge-shaped  circuminjection  is  made  according  to  the  method 
of  Hackenbruch  (Fig.  78,  1-4-5).  From  point  1  marked  on  the  chin  the  needle,  guided 
by  the  finger  in  the  mouth,  is  introduced  beneath  the  mucous  membrane  to  point  4, 
infiltrating  the  entire  line;  the  needle  is  then  partly  withdrawn  and  a  subcutaneous 
infiltration  is  made  to  point  4.  A  similar  injection  is  made  toward  point  5.  For 
this  injection,  as  is  shown  in  Fig.  78,  20  to  25  c.c.  of  a  0.5  per  cent,  novocain-supra- 
renin  solution  is  necessary;  the  entire  area  as  indicated  by  lines  1-4-5  is  rendered 
insensitive.  In  cases  of  carcinoma  the  line  of  injection  must  be  removed  some  dis- 
tance from  the  lesion,  points  4  to  5,  as  a  rule,  being  at  the  angle  of  the  mouth.  The 
wedge-shaped  excision  in  carcinoma  should  not  correspond  to  the  lines  of  injection 
1-4-5,  but  should  lie  within  these  lines.  It  is  possible  in  this  way  to  avoid  the  infil- 
tration of  diseased  tissues.    In  case  it  is  desired  to  anesthetize  the  larger  part  or  the 


I 
J 


OPERATIONS  ON   THE  HEM) 


239 


entire  lower  lip  with  the  adjacent  skin  of  the  chin,  2  points  for  injection  are  made 
at  2  to  3  (Fig.  78),  and  the  tissues  infiltrated  in  the  lines  designated  by  9-2-3-10. 
^Vllere  the  soft  parts  join  the  bone,  injection  is  first  made  deep  to  the  periosteum, 
then  under  the  skin.  The  remaining  portion  of  the  injection  is  performed,  as  already 
described,  guided  by  a  finger  in  the  mouth  and  using  0.5  per  cent,  novocain-supra- 
renin  solution.  Complete  anesthesia  is  not  obtained  by  this  injection;  to  do  this  it 
is  necessary  to  anesthetize  the  inferior  mental  nerves  at  their  exit  from  the  foramina 
a  and  h,  or  to  block  the  inferior  alveolar  nerve  at  the  lingula.  After  this  the  entire 
field  of  operation  and  the  underlying  bone  should  be  rendered  insensitive.     Fig.  78 


Fig.  77. — Technique  for  injection  of  the 
lower  lip. 


Fig.  78. — Circuminjection  of  the  lower 
lip  and  chin,  a,  b,  points  of  emergence  of 
the  mental  nerve. 


shows  how  the  anesthetic  field  of  the  cheek  and  submental  region  can  be  enlarged, 
this  is  done  by  marking  additional  points  for  injection  at  6  and  7.  By  circuminjection 
the  field  designated  by  9-7-2-8-3-7-10  or  portions  of  it  can  then  be  rendered  anes- 
thetic. The  injection  from  2  to  6  is  carried  out  as  was  described  for  lower  lip 
anesthesia  and  from  6  to  9  like  that  for  transverse  cheek  incisions.  Where  plastic 
operations  are  to  be  performed  on  the  face  with  pediculated  flaps,  the  method  as 
described  above  should  be  used,  except  that  the  anesthetic  should  be  injected  some 
little  distance  from  the  pedicle,  for  self-evident  reasons.  The  form  of  anesthesia 
must  therefore  be  guided  accordingly. 


240 


LOCAL  ANESTHESIA 


OPERATIONS    ON    THE   NASAL   CAVITIES 
THE    NOSE. 


AND    THE   BONY   PART    OF 


The  nasal  cavities  in  their  anterior  portions  are  innervated  by  the  ethmoidal  and 
'  ophthalmic  nerves,  the  posterior  portion  by  the  maxillary  nerve.  Figs.  79  and  80 
show  the  nerve  distribution  schematically.  The  sphenoid  cavity  and  the  antrum  of 
Highmore  are  supplied  by  the  maxillary  nerve  alone.  The  frontal  sinuses  are  sup- 
plied by  the  ethmoidal  nerves.  The  cells  of  the  ethmoid  are  supplied  by  both  of 
these  nerves. 


Fig.  79. — Innervation  of  the  nasal  septum.     1,  olfactory  nerve;  2  ethmoidal  nerve;  3,  maxillary  nerve. 

Cocainization  of  the  nasal  mucous  membrane  has  been  of  marked  importance  in 
the  development  of  rhinology.  The  exact  examination  of  the  nasal  cavities  and  acces- 
sory sinuses  as  well  as  the  performance  of  many  operations  were  heretofore  impossible. 
This  agent  not  only  renders  the  mucous  membrane  insensitive  with  an  inhibition  of 
its  reflexes  but  also  enlarges  the  nasal  cavities  through  its  power  to  contract  the 
bloodvessels  of  the  mucous  membrane,  making  them  much  more  accessible.  This 
same  condition  can  at  present  be  produced  with  many  other  anesthetic  substances 
by  the  addition  of  suprarenin,  but  cocain  has  never  been  displaced  in  rhinology  by 
the  newer  substitutes.  Among  the  newer  preparations  alypin  has  been  highly  praised 
by  both  Seifert  and  Ruprecht.  They  use  this  agent  in  a  10  per  cent,  solution,  Ruprecht 
adding  suprarenin. 


1 


OPERATIOXS  OX    THE   HEAD 


241 


Cocaiu  solutions  are  used  in  the  following  manner  (these  direetions  are  given  by 
Bresgens):  "A  bit  of  eotton  is  fastened  to  a  very  fine  sound  and  saturated  with  the 
anesthetie  solution.  After  illuminating  the  nasal  cavities  the  cocain  solution  is 
gently  rubbed  over  the  nasal  mucous  membrane,  beginning  in  the  anterior  portion 
and  proceeding  backward,  also  touching  the  middle  and  lower  nasal  tracts.  The 
patient  is  then  directed  to  bend  his  head  sharply  forward  so  that  the  anesthetic  does 
not  run  into  the  throat,  he  is  also  at  the  same  time  directed  to  blow  the  side  of  the 
nose  which  has  been  anesthetized,  the  opposite  half  of  the  nose  being  closed.  The 
middle  portion  of  the  nasal  cavity  is  anesthetized,  the  anesthesia  being  continued 
high  up  in  the  nose,  after  which  the  lower  portions  are  again  touched  with  the  cocain 
solution.  This  entire  procedure  is  repeated  once  more,  after  which  in  most  cases  the 
entire  nasal  mucosa  becomes  anesthetic  and  shrunken.  In  the  majority  of  cases 
the  second  application  of  the  anesthetic  is  sufficient — in  some  cases  one  application, 
whereas  in  other  cases  four  or  more  applications  must  be  used." 


Fig.  80. — Innervation  of  the  lateral  wall  of  the  nasal  cavity.    1,  olfactory 
2,  ethmoidal  nerve;  3,  maxillary  nerve. 


In  cases  where  it  is  only  necessary  to  sound  the  frontal  or  maxillary  sinuses,  it  is 
sufficient  to  anesthetize  only  the  mid-nasal  tracts,  and  to  place  a  small  cotton  tampon 
saturated  with  the  solution  at  the  outlet  of  the  cavity  to  be  sounded. 

Anesthesia  produced  in  this  way  is  limited  to  the  mucous  membrane.    Whenever 

it  becomes  necessary  to  anesthetize  the  bony  or  cartilaginous  part  of  the  nose  the 

submucous  membranes  must  be  infiltrated  with  a  2  per  cent,  novovain-suprarenin 

solution.    This  is  readily  carried  out  upon  the  septum  and  makes  the  operation  for 

16 


242 


LOCAL  ANESTHESIA 


deviations  of  this  structure  very  easy.  The  injection  is  made  with  a  1  c.c.  syringe 
and  very  fine  needle.  Beginning  anteriorly  the  injection  is  extended  backward  on  both 
sides  of  the  septum  as  far  as  the  limit  of  the  field  of  operation.  The  desired  operation 
can  then  be  very  easily  performed  owing  to  the  anemia  from  the  suprarenin.  Killian 
advises  that  injections  be  made  at  the  points  of  emergence  of  the  ethmoidal  and 
nasopalatine  nerves  (see  page  214).  In  regard  to  the  details  of  anesthesia  for  the 
numerous  superficial  operations  in  this  particular  field  the  reader  is  referred  to  works 
on  rhinology. 


.  81. — Carcinoma  of  the  skin  and  bony 
parts  of  the  nose. 


Fi(i.  ,S2.— After  operation,  patl 
unable  to  open  eyes  owing  to  edei 
the  upper  lids. 


For  extensive  operations  on  the  bony  structure  of  the  nose  neither  anesthesia  of 
the  mucous  membrane  nor  submucous  injections  from  inside  the  nose,  nor  the 
circuminjection  as  described  on  page  237  will  be  suflScient.  In  such  cases  the 
method  as  described  by  Peuckert  and  Offerhaus  must  be  used.  An  example  will 
probably  best  explain  the  technique.  Take,  for  instance,  excision  of  a  carcinoma  of 
the  nose  in  which  not  only  the  entire  nose  was  removed,  but  also  the  nasal  bones, 
the  edges  of  the  pyriform  aperture,  the  anterior  part  of  the  hard  palate,  and  the 
exenteration  of  the  entire  interior  of  the  nose  (see  Fig.  82).  The  mjection  begins 
with  blocking  of  both  maxillary  nerves  from  the  lower  border  of  the  zygoma  (see 
page  216)  and  blocking  of  the  ethmoidal  nerves  by  a  bilateral  median  orbital  injection 
(page  212).  The  injection  of  the  outer  nose  with  a  0.5  per  cent,  novocain-suprarenin 
solution  is  carried  out  according  to  Fig.  83,  in  which  the  ix)ints  for  injection  are  the 


OI'Hh'ATIONS   ON    TIN']   II KM) 


243 


same  as  tliose  used  for  l)l()ckiii,u-  the  maxillary  iier\e.  A  third  [joint  for  injeetion  lies 
on  the  bridge  of  the  nose.  The  operation  is  painless  and  bloodless.  Fig.  <S2  shows 
the  patient  just  after  eompletion  of  the  operation.  The  eyelids  are  edematous,  for 
which  reason  the  patient  is  not  able  to  open  the  eyes. 


Fig.  83. — Figure 


nt  for  the  median  orbital  injection; 


With  this  same  procedure  the  author  has  repeatedly  performed  the  preliminary 
operation  to  freely  expose  the  interior  of  the  nose  and  the  base  of  the  skull;  for  the 
reflexion  of  the  outer  nose  according  to  Kocher;  and  for  the  temporary  reflexion  of 
both  bones  of  the  upper  jaw,  also  according  to  Kocher,  for  the  removal  of  tumors. 
It  is  advisable  when  operating  upon  tumors  at  the  base  of  the  skull  and  the  pharynx 
to  again  inject  the  visible  portions  of  the  pharyngeal  wall  after  exposing  the  operative 
field,  and  to  infiltrate  the  nasopharyngeal  fibroma  at  its  attachment  before  completing 
the  extirpation. 

Any  one  who  has  seen  this  operation  carried  out  under  local  anesthesia,  and  has 
learned  the  method  of  blocking  the  trigeminus  trunk,  would  never  again  think  of 
performing  it  under  general  anesthesia  or  without  the  anemia  induced  by  suprarenin. 
For  operation  upon  the  hypophysis  carried  out  through  the  nose  no  more  suitable 
means  of  anesthesia  could  be  found  than  the  one  just  described. ^ 


1  V.  Eisolsberg,  Archiv.  f.  klin.  Chir.,  vol.  100,  p.  70). 
tions  upon  the  hypophysis  l\v  means  of  the  external  circ 
solution  for  the  purpose  of  checking  hemorrhage. 


■.  Eiselsherg  in  the  past  has  also  performed  opera- 
minjection  of  a  0.5  per  cent,  novocain-suprarenin 


244 


LOCAL  ANESTHESIA 


OPERATIONS    UPON    THE    FRONTAL    SINUSES. 

The  operations  upon  the  frontal  sinuses  which  previously  were  performed  under 
local  anesthesia  were  confined  to  the  simple  opening  of  these  cavities  with  a  chisel 
after  infiltration  of  the  soft  parts  overlying  the  small  operative  field.  This  anesthesia 
has,  as  a  rule,  proved  insufficient.  Peuckert  was  the  first  to  develop  our  present  tech- 
nique of  anesthesia  for  the  radical  operation,  consisting  in  complete  removal  of  the 
anterior  and  posterior  wall  known  as  Killian's  operation.  This  technique  was  partially 
described  in  the  second  (German)  edition  of  this  work;  13  cases  were  reported  later  in 
which  the  radical  operation  was  performed,  some  being  unilateral,  others  bilateral. 


-"^B 


Fig.  84. — Figun*  loi  ( in  uiuiujettion  in  oper- 
ations upon  the  fiontal  sinuse':!.  1,  point  for  the 
medial  orbital  injection;  2,  point  for  the  injection 
of  the  maxillary  nerve. 


Fig.   85. — Figure  fur  cireuminjection  in  bilateral 
radical  operations  upon  the  frontal  .sinuses. 


It  is  usually  sufficient  to  anesthetize  with  the  median  orbital  injection  (see  page 
212),  introducing  the  anesthetic  solution  in  the  roof  of  the  orbit;  the  lateral  injection 
can  then  be  omitted.  Previously  the  attempt  was  made  to  block  the  second  branch 
of  the  trigeminus  which  innervates  the  nasal  mucous  membrane  by  applying  solutions 
of  cocain  or  alypin  to  the  mucous  membrane  before  beginning  the  operation.  Inas- 
much as  patients  complained  of  pain  when  connecting  the  frontal  sinuses  with  the 
nose  and  on  opening  the  posterior  cells  of  the  ethmoid,  it  is  now  customary  to  block 
the  maxillary  nerve  by  preference  at  the  foramen  rotundum  (page  216) .  The  operative 
field  is  circuminjected  in  the  unilateral  operation  from  seven  points  of  entrance, 


OPERATIONS  ON   THE  HEAD 


245 


Fig.  86. — Radical  operation  for  empyema  of  the  frontal  sinuses.     (Killian's  operation.) 


Fig.   87.— Radical  operation  for  empyema  of  the  frontal  sinuses.     Complete  removal  of  the  ] 

lateral  and  posterior  wall.  i 


246  LOCAL  ANESTHESIA 

the  position  of  whic-h  are  indicated  in  Fig.  84.  One  of  these  corresponds  to  the  point 
necessary  for  the  median  orbital  injection.  The  operative  field  on  the  forehead  and 
nose  is  circuminjected  from  points  on  the  orbital  border,  as  shown  in  the  diagram. 
Injections  are  then  made  beneath  this  edge  and  under  the  roof  of  the  orbit.  For  the 
blocking  of  the  ethmoid  and  maxillary  nerve  10  c.c.  of  a  2  per  cent,  novocain-supra- 
renin  solution  is  necessary.  For  the  circuminjection  40  to  50  c.c.  of  a  0.5  per  cent, 
novocain-suprarenin  solution  is  used.  The  technique  for  injection  in  bilateral  opera- 
tions is  shown  in  Fig.  85.  The  field  of  operation  after  these  injections  is  absolutely 
painless.  The  ethmoidal  cells  can  be  removed  as  far  as  necessary,  also  the  anterior 
and  upper  wall  of  the  frontal  sinuses.  The  orbit  is  accessible  even  to  the  deepest  parts 
so  that  the  opening  can  be  made  through  the  nasal  bone  and  mucous  membrane  into 
the  nasal  cavities.  The  anemia  of  the  operative  field  simplifies  this  procedure  very 
much.  Nobody  will  be  induced  to  perform  this  operation  under  general  anesthesia 
after  observing  the  accessibility  and  learning  the  advantages  of  the  method  just 
described.  Figs.  86  and  87  represent  photographs  taken  of  two  patients  during  and 
at  the  completion  of  the  operation. 


OPERATIONS    UPON    THE   JAWS. 

The  Operative  Treatment  of  Empyema  of  the  Antrum  of  Highmore. — There  are 
really  only  two  operations  for  treating  suppurations  in  the  upper  jaw:  (1)  the  opening 
of  the  antrum  of  Highmore  from  the  canine  fossa  in  acute  cases,  and  (2)  the  removal 
of  the  anterior  and  nasal  wall,  including  a  portion  of  the  pyriform  aperture  in  chronic 
suppurative  processes,  according  to  Friedrich.  The  operation  on  the  bone  in  the 
latter  case  can  be  carried  out  by  incision  of  the  outer  soft  parts  or  from  within  the 
mouth,  if  it  can  be  opened  sufficiently  wide  and  the  upper  lip  is  fairly  movable.  The 
use  of  local  anesthesia  simplifies  this  radical  operation  so  that  the  patient  can  be 
discharged  with  a  healed  wound  after  one  to  two  weeks. 

The  upper  jaw  is  entirely  innervated  by  the  maxillary  nerve.  In  the  radical  opera- 
tion the  ethmoidal  nerve  is  also  encountered.  Both  of  these  trunks  must  be  blocked. 
Anesthesia  of  the  maxillary  nerve  in  operations  for  empyema  of  the  upper  jaw  was 
suggested  by  Muench  in  1909.  This  anesthesia  is,  however,  not  sufficient,  the  tech- 
nique of  injection  being  of  secondary  importance  to  the  pronounced  suprarenin 
anemia. 

Anesthesia  for  the  radical  operation  is  performed  in  the  following  manner:  Three 
points  of  entrance  are  marked  as  shown  in  Fig.  88,  the  first  and  second  points  cor- 
responding to  the  point  of  injection  for  blocking  the  maxillary  and  ethmoidal  nerves. 
The  third  adjoins  the  ala  of  the  nose.    From  point  1,  5  c.c.  of  a  2  per  cent,  novocain- 


OPERATIONS  OX   TIIK   HEAD 


247 


sii])rareniii  solution  is  injected  into  the  i)teryii'oi)alatine  fossa,  and  upon  the  with- 
drawal of  the  needle  5  e.c.  of  a  0.5  per  cent,  novocain-suprarenin  solution  is  injected 
to  the  maxillary  tubercle.  From  point  2  the  median  orbital  injection  is  made  with 
2..")  c.c.  of  a  2  per  cent.  no\-ocain-suprarenin  solution  (see  page  217)  after  which  the 
soft  parts  are  infiltrated,  guided  by  a  finger  in  the  mouth,  in  a  line  from  point  1  to  the 
angle  of  the  mouth,  just  as  was  done  in  the  transverse  splitting  of  the  cheek  (page 
238).  From  15  to  20  c.c.  of  a  0.5  per  cent,  novocain-suprarenin  solution  is  used. 
This  injection  excludes  the  lateral  innervation  from  the  third  branch  of  the  trigem- 
inus,  at   the  same  time  causing  contraction  of   the  end  branches  of  the  external 


Fig.  88. — Circuminjecti 
1,  point  of  injectit 


n  for  the  radical  operation  for  empyema  of  the  antrum  of  Highmore. 
1  for  the  maxiUary  nerve;  2,  point  for  median  orbital  injection. 


maxillary  artery.  From  point  3,  10  to  15  c.c.  of  a  0.5  per  cent,  novocain-suprarenin 
solution  is  injected  along  the  pyriform  aperture  under  the  alse  of  the  nose  and  frenu- 
lum and  in  the  midline  of  the  upper  lip  as  far  as  the  red  margin.  The  latter  can 
be  more  readily  performed  without  another  point  for  injection  if  the  lip  is  raised  and 
drawn  toward  the  opposite  side.  The  injection  in  the  upper  lip  controls  the  over- 
lapping nerves  and  arteries  from  the  opposite  side.  The  radical  operation  cannot 
be  carried  out  without  pain  or  loss  of  blood,  either  from  without,  according  to  the 
method  of  Friedrich,  or  from  within  the  mouth  after  cutting  the  mucous  membrane 
from  the  middle  line  to  the  attachment  of  the  zygomatic  process  to  the  maxilla. 
For  the  simple  opening  of  the  antrum  of  Highmore  from  the  canine  fossa  the  same 


248  LOCAL  ANESTHESIA 

form  of  injection  is  used  as  for  the  extraction  of  several  teeth  from  the  upper  jaw  on 
one  side  (page  258),  except  that  the  gums  may  be  disregarded.  The  injection  of  the 
anterior  surface  of  the  upper  jaw  ehminates  the  innervation  from  the  infra-orbital 
nerves  which  pass  into  the  antrum  of  Highmore,  and  at  the  same  time  renders  the 
operative  field  bloodless.  The  other  injection  at  the  tubercle  of  the  maxillary  bone 
blocks  the  superior,  posterior,  and  median  alveolar  nerves  (Fig.  95). 


Fig.  89. — Direction  of  the  needle  in  c 


Both  of  these  injections  can  be  readily  made  from  a  single  point  of  entrance  situated 
beneath  the  lower  angle  of  the  zygoma  (Fig.  89).  A  wheal  is  made  at  this  point  and 
the  needle  inserted  below  the  infra-orbital  foramen  and  pushed  as  far  as  the  bone  of 
the  nose.  At  this  point  5  c.c.  of  a  2  per  cent,  novocain-suprarenin  solution  are 
injected.  The  needle  is  now  partially  withdrawn  and  passed  toward  the  posterior 
surface  of  the  upper  jaw,  injecting  at  this  point  5  c.c.  of  a  2  per  cent,  or  10  c.c.  of  a 
1  per  cent,  novocain-suprarenin  solution.  The  introduction  of  the  needle  to  the 
foramen  is  not  necessary.  The  injection,  as  is  frequently  done  by  dentists,  can  be 
carried  out  from  within  the  mouth  (see  page  257).  The  customary  injection  of  the 
anterior  surface  of  the  upper  jaw  is  not  sufficient  for  complete  anesthesia  of  an  acutely 
inflamed  sensitive  mucosa  of  the  antrum  of  Highmore,  as  can  be  readily  understood 
from  the  inner^•ation  of  the  upper  jaw. 


OPERATIONS  ON   THE  HEAD 


249 


The  Resection  of  the  Upper  Jaw. — A  resection  of  l)oth  liaKes  of  tlie  upper  jaw, 
including  the  hard  pahite,  was  performed  by  Matas  in  19(H)  inider  local  anesthesia. 
He  proceeded  as  follows:  A  long  needle  was  passed  through  the  sphenomaxillary 
fissure  to  the  sphenopalatine  fossa  of  both  sides  and  injection  of  1.5  c.c.  of  a  1  per 
cent,  cocain  solution  made  in  order  to  block  the  infra-orbital  ner\'es.  In  about  five 
minutes  the  skin  of  the  cheek,  upper  lip  and  the  alje  of  the  nose  became  anesthetic. 
The  septum  and  hard  palate  were  infiltrated  direct  with  Schleich's  solution.  The 
operation  was  carried  out,  the  only  painful  part  being  the  cutting  of  the  vomer. 
This  operation  was  not  again  attempted;  in  fact,  before  the  introduction  of  suprarenin 
it  was  not  possible  to  perform  an  operation  of  this  kind  and  duration  and  be  certain 


Fig.  90. — Circuminjection  for  unilatc 
and  lateral  orbital  inject 


ot  the  upper  jaw.     1,  la,  points  for  median 
t  for  injeetiug  maxillary  nerve. 


of  the  anesthesia.  Total  and  partial  resections  of  the  upper  jaw  are  today  performed 
under  local  anesthesia  as  the  anesthetic  of  choice.  Peuckert  in  1911  was  the  first  to 
report  the  technique  of  the  injection,  and  the  author  performed  resections  of  the  upper 
jaw  eight  times  under  this  method  of  anesthesia.  Oft'erhaus,  from  his  studies  of  the 
techniciue  of  alcohol  injections  in  trigeminal  neuralgia,  also  used  local  anesthesia 
for  resection  of  the  upper  jaw. 

For  the  unilateral  total  resection  of  the  ui)per  jaw,  if  the  incision  is  not  to  extend 
beyond  the  middle  line,  the  unilateral  orbital  injection  (page  212)  with  the  blocking 
of  the  maxillary  nerve  (page  216)  is  sufhcient.  If  the  orbital  floor  is  to  be  preserved, 
the  lateral  orbital  injection  is  not  necessary.  The  external  field  of  operation  is  cir- 
cuminjected,  as  is  shown  in  Fig.  88,  for  the  purpose  of  checking  hemorrhage  as  well 


250 


LOCAL  ANESTHESIA 


as  to  exclude  the  innerAation  from  the  third  branch  of  the  trigeminus  and  other  skin 
nerves  from  the  opposite  side.  Four  points  of  injection  are  necessary.  The  upper 
Up  can  readily  be  injected  from  the  point  adjoining  the  al?e  of  the  nose  (see  page  248). 
The  hard  and  soft  palate  must  also  be  infiltrated  where  they  are  to  be  cut.  For  the 
central  injection  10  c.c.  of  a  2  per  cent,  novocain-suprarenin  solution  are  necessary 
and  80  to  100  c.c.  of  a  0.5  per  cent,  novocain-suprarenin  solution  for  the  circum- 
injection.  Haertel  also  advises  painting  the  palate  and  pharynx  with  a  10  per  cent, 
cocain  solution  to  prevent  reflex  vomiting.  A  better  substitute  for  this  solution 
would  be  a  10  per  cent,  alypin-suprarenin  solution.  In  case  the  orbit  is  to  be  cleaned 
out,  10  to  15  c.c.  of  a  0.5  or  1  per  cent,  novocain-suprarenin  solution  are  injected 


Fig.  91. — Resection  of  the  upper  jaw  with 


al  of  contents  of  orljit  under  local  anesthes 


without  fear  into  the  posterior  portion  of  the  orbit.  The  latter  injection  can  be 
made  in  case  it  becomes  necessary  to  remove  the  eye  during  the  operation,  the  patient's 
consent  of  course  being  obtained.  This  latter  operation  is  photographically  shown 
in  Fig.  91.    Fig.  92  shows  a  case  in  which  the  floor  of  the  orbit  was  not  removed. 

In  two  cases  of  resection  of  the  upper  jaw,  described  by  Offerhaus,  it  was  necessary 
to  block  the  third  branch  of  the  trigeminus  owing  to  the  extent  of  the  tumor.  The 
invasion  of  the  sphenopalatine  fossa  by  the  tumor  led  Ofterhaus  in  two  cases  not  to 
interrupt  the  maxillary  nerve  in  the  foramen  rotundum.  The  author  had  a  similar 
experience  in  one  case.  In  this  case  we  were  able  to  complete  the  operation  by  the 
use  of  5  c.c.  of  chloroform.    In  similar  cases  today  we  would  advise  the  injection  of 


OPERATIONS  OX    THE   HEM)  251 

the  (iasscrian  ganglion  according  to  Ilacrtcl's  method.    The  external  circuminjeetion 
is   also   necessary. 

In  three  cases  the  author  has  performed  the  temporary  resection  of  the  upper  jaw 
(under  local  anesthesia)  according  to  the  method  of  Kocher  for  the  remo\al  of  tumors 
of  the  nasopharynx.  The  anesthesia  was  similar  to  that  described  for  operations 
upon  the  nose  and  shown  in  Fig.  81.  It  was  also  necessary  to  infiltrate  the  hard  and 
soft  palate  in  the  line  of  division.  The  operation  under  local  anesthesia  is  surprisingly 
easy  owing  to  the  absence  of  the  usual  severe  hemorrhage. 


Fig.  92. — Resection  of  the  uppei  jaw  for  carfinoiiKi 

of  the  orbit.     The  removed  poitioi 


tioii  of  the  floor 


Local  anesthesia  has  completely  changed  the  operation  for  resection  of  the  upper 
jaw.  It  cannot  be  considered  a  serious  operation  today,  having  lost  its  terrors,  and 
the  difficulties  and  dangers  have  been  materially  lessened.    A  preliminary  operation 


252 


LOCAL  ANESTHESIA 


is  not  necessary,  such  as  tracheotomy,  ligation  of  the  carotids  or  the  intubation  of 
Kuhn,  as  there  is  scarcely  any  hemorrhage.  The  operation  can  now  be  completed 
with  certainty  and  without  haste  and  loss  of  blood.  The  patients  are  as  well  after 
the  operation  as  they  were  before;  they  are  never  collapsed.  It  is  rarely  necessary 
for  them  to  take  to  their  bed.  In  10  resections  of  the  upper  jaw  we  have  not  lost  one, 
and  have  never  had  a  postoperative  lung  complication.  Haertel  reports  9  cases 
from  Bier's  clinic  carried  out  under  local  anesthesia  and  states  that  the  introduction 
of  local  anesthesia  in  major  operations  upon  the  areas  supplied  by  the  trigeminus 
is  an  advancement  of  vital  importance. 


Fig.  93.— Circn 


inor  operations  upon  the  lower  jaw. 


Operation  Upon  the  Lower  Jaw. — The  lower  jaw  and  floor  of  the  mouth  are 
innervated  l\v  the  mandibular  nerve.  This  nerve  must  be  blocked  in  all  operations 
upon  the  lower  jaw  either  at  the  lingula  or,  if  the  field  of  operation  extends  to  the 
base  of  the  skull,  at  the  foramen  ovale.  In  all  operatioiis  made  from  without,  the 
cervical  nerves  must  be  blocked  by  subfascial  or  subcutaneous  circuminjections  of 
the  field  of  operation.  As  an  example  of  the  simplest  case  Yve  might  take  a  suture 
of  a  fracture  or  other  minor  operation  on  the  horizontal  ramus  of  the  jaw.  The  opera- 
tion is  begun  by  injecting  at  the  lingula  (page  220) .  The  field  of  operation  is  circum- 
injected  from  3  points  with  a  0.5  per  cent,  novocain-suprarenin  solution  as  shown 
in  Fig.  93.  The  bone  can  then  be  exposed  in  the  injected  area  and  cut,  chiseled  or 
sutured.  Fig.  94  shows  the  plan  for  circuminjection  in  resection  of  the  left  horizontal 
ramus  of  the  lower  jaw  for  carcinoma  of  the  alveolar  process.  The  submaxillary 
salivary  glands  and  lymph  glands  were  removed  at  the  same  time  with  the  bone. 
The  mandibular  nerve  was  blocked  on  both  sides  at  the  lingula.  In  case  the  jaw  is 
to  be  disarticulated,  it  will  be  necessary  to  block  the  mandibular  nerve  at  the  foramen 
ovale  (page  224)  and  the  lateral  lines  of  circuminjection  of  Fig.  94  will  also  have  to 
be  extended  somewhat  farther  back.  In  all  cases  it  is  advisable  for  purposes  of  pro- 
ducing anemia  to  infiltrate  the  entire  floor  of  the  mouth  with  a  0.5  per  cent,  novocain- 
suprarenin  solution  from  one  of  the  points  beneath  the  border  of  the  jaw.    This  should 


I 


OPERATIONS  ON   THE  HEAD  253 

be  done  even  though  tlie  entire  area  has  been  prexionsly  rendered  anesthetie  by 
a  eentral  injection.  The  technique  for  injections  in  operations  upon  the  neck  must 
frequently  be  combined  with  injections  of  the  lower  jaw  in  cases  in  which  the 
lymphatics  are  to  be  removed.  The  temporary  cutting  of  the  lower  jaw  will  be 
described  in  connection  with  operations  upon  the  tongue  and  floor  of  the  mouth. 


Fig.  94. — Circuminjection  for  resection  of  the  left  ramus  of  the  lower  jaw  with  removal  of  the 
submaxillary  salivary  gland  and  lymph  glands. 


EXTRACTION    OF    TEETH    AND    OTHER    OPERATIONS    UPON    THE    ALVEOLAR 
PROCESSES    OF    THE    UPPER    AND   LOWER   JAWS. 

History. — Ether  and  ethyl  chloride  sprays  which  were  formerly  very  much  in  use 
for  the  extraction  of  teeth  give  very  unsatisfactory  results.  Even  when  ethyl  chloride 
spray  is  successful  for  the  painless  extraction  of  teeth,  it  should  be  borne  in  mind 
that  the  inhalation  of  small  quantities  of  the  drug  could  have  produced  sufficient 
general  anesthesia  to  render  the  entire  body  insensitive  for  a  short  time  (Kulenkampff ) . 
This  ethyl  chloride  drunk  is  possibly  satisfactory  for  the  extraction  of  a  single  tooth, 
but  its  action  is  not  local  and  the  anesthesia  could  be  better  carried  out  by  the  inhala- 
tion of  ethyl  cliloride  rather  than  its  application  to  the  gums. 

The  introduction  of  cocain  opened  up  new  paths  for  practical  local  anesthesia 
in  dentistry.  This  preparation  was  injected  beneath  gums  in  the  neighborhood  of 
the  tooth  to  be  extracted.  Attempts  were  also  made  to  anesthetize  the  inferior 
alveolar  nerves  by  means  of  perineural  injection.  The  painless  extraction  of  a  tooth 
by  means  of  subgingival  injection  is  brought  about  by  the  diffusion  of  this  drug 
through  the  bone  to  pulp  cavity  and  the  nerve  supplying  the  peridental  membrane. 
That  dissolved  substances   can   actually  diffuse   through  bone    was  demonstrated 


254  LOCAL  ANESTHESIA 

upon  a  cadaver  by  Dzierzawskis,  who  showed  that  colored  sohitions  injected  beneath 
the  gums  diffuse  to  a  greater  or  lesser  extent  into  the  bone,  in  the  upper  jaw 
reaching  as  far  as  the  floor  of  the  antrum  of  Highmore.  It  is  very  improbable  (see 
page  153)  that  solutions  injected  beneath  the  mucosa  or  periosteum  can  be  mechan- 
ically forced  into  the  bone.  By  means  of  such  an  injection  the  fluid  under  great 
pressure  will  naturally  take  the  course  of  least  resistance  which  would  be  in  the  soft 
parts  surrounding  the  bone.  We  have,  therefore,  come  to  believe  that  this  process  is 
carried  on  by  diffusion.  The  extent  of  the  anesthetic  or  colored  solution  so  injected 
must  depend  upon  the  concentration  of  the  quantity  injected  into  the  gums.  This 
must  be  true,  inasmuch  as  the  diffused  substance  becomes  more  and  more  dilute  the 
farther  it  is  removed  from  the  point  of  injection,  and  therefore  the  solutions  which 
reach  the  pulp  and  innervate  the  roots  must  be  of  sufficient  concentration  to  be 
effective.  The  agent  requires  considerable  time  to  reach  the  points  above  mentioned 
and  a  tooth  can  never  be  extracted  immediately  without  pain,  no  matter  how  much 
has  been  previously  injected  into  the  gums. 

Owing  to  the  danger,  injections  of  5  to  20  per  cent,  of  cocain  solutions  into  the 
gums  were  soon  given  up  by  dentists  and  replaced  by  solutions  of  1  to  2  per  cent. 
The  injection  of  a  1  per  cent,  cocain  solution  into  the  gums  has  been  proved  without 
danger  in  a  large  number  of  cases,  Bleichsteiner  in  1892  reported  1400  extractions. 
Following  the  use  of  dilute  solutions  the  anesthesia  of  the  alveolar  process  became 
insufficient.  It  was  possible  to  anesthetize  the  gums  and  alveolar  periosteum  with 
certainty,  but  the  pulp  and  peridental  membrane  could  rarely  be  sufficiently  anes- 
thetized for  dental  operations.  The  author  does  not  believe  that  Legrand,  a  pupil  of 
Reclus,  should  be  credited  with  the  statement  that  all  extractions  can  be  rendered 
painless  with  the  use  of  a  1  per  cent,  solution  of  cocain,  nor  does  he  believe  those  who 
are  sceptical  regarding  the  use  of  any  injection.  Laewen  and  Quere  made  the  following 
statements  regarding  cocain  injected  into  the  gums  and  as  to  its  anesthetic  effect 
upon  teeth  with  living  pulp:  (1)  in  no  case  is  absolute  anesthesia  obtained,  (2)  in  the 
majority  of  cases  there  is  a  marked  lessening  of  pain,  (3)  in  a  certain  number  of  cases 
cocain  does  not  seem  to  produce  a  perceptible  analgesia.  Quere,  Reclus,  and  Dastre 
agree  that  in  the  latter  class  of  cases  osteoperiostitis  of  the  alveolar  process  is  present. 
Those  with  the  formation  of  abscesses  and  inflammatory  infections  of  the  gums  are 
the  cases,  how^ever,  in  which  anesthesia  is  most  necessary.  The  conditions  are  dif- 
ferent for  the  physician  because  as  he  sees  patients  whose  teeth  have  been  neglected 
and  frequently  extracts  teeth  which  the  dentist  could  have  preserved.  For  ten  years 
the  author  has  extracted  teeth  with  a  1  per  cent,  cocain  solution  and  he  agrees  entirely 
with  Quere.  This  applies  not  only  to  cases  as  above  mentioned  but  also  to  persons 
with  thick  bones  in  whom  the  anesthesia  frequently  failed  in  extraction  of  the  lower 
molars.    The  patient  could  never  be  promised  a  painless  extraction,  for  which  reason 


OPE  RAT  I  ox  S  0\    THE   HEAD  255 

this  method  of  mjectiou  has  never  been  generally  accepted.  Accordint;'  to  the  anthor's 
experience  the  anesthesia  is  more  certain  if  a  more  dilute  solution  is  used  and  the 
gums  and  ah'eolar  periosteum  infiltrated  with  Schleich's  solution.  One  thing  is 
certain,  that  these  solutions  do  not  produce  serious  general  symptoms  when  used 
for  these  injections.  The  infiltration  of  the  gums  and  periosteum  with  Schleich's 
solution  only  produces  a  satisfactory  anesthesia  when  the  tooth  to  be  extracterl  has 
been  freed  of  its  pulp. 

The  local  anesthetic  methods  have  not  been  materially  improved  by  the  countless 
combinations  of  various  anesthetic  substances.  With  a  2  or  3  per  cent.  (8-eucain 
(Reclus,  Thiesing)  and  tropocain  solutions  (Dillenz  and  others)  approximately  the 
same  efl'ect  is  obtained  as  from  a  1  per  cent,  cocain  solution.  ]\Iore  highly  con- 
centrated solutions  of  these  agents  are  not  free  from  possible  injury  and  their  use 
may  be  associated  with  considerable  danger.  A  description  of  the  various  substi- 
tutes for  cocain  has  already  been  described  in  Chapter  \ll.  Reports  of  injury  to 
the  gums  following  the  injection  of  anesthetic  solutions  occupy  a  most  important 
place  in  dental  literature.  All  of  the  pain-relieving  drugs  have  been  attended  with 
swelling  and  edema  of  the  tissues  following  injection,  but  it  is  difficult  to  determine 
whether  the  swelling  should  be  attributed  to  the  injection  or  the  extraction.  The 
most  carefully  performed  extraction  is  always  followed  by  more  or  less  crushing  of 
the  bone  or  soft  parts  and  naturally  takes  place  in  an  operative  field  which  is  always 
infected  with  bacteria.  If  substances  which  produce  tissue  injuries  are  not  used,  as 
for  instance  guaiacol,  and  if  the  solutions  are  sterile  and  contain  the  proper  quantity 
of  salt,  the  swelling  and  edema  should  not  be  attributed  to  the  injection,  but  rather 
to  the  extraction  (Laewen) .  A  pronounced  improvement  was  obtained  in  anesthetizing 
the  aheolar  processes  when  Wiener,  and  later  Schleich,  advised  infiltrating  the  perios- 
teum first  with  cocain  solution,  followed  by  cooling  the  cocainized  tissues  with 
the  ethyl  chloride  spray. 

The  advantage  of  this  method  depends  upon  the  fact  that  more  dilute  solutions 
of  cocain  can  be  used  when  the  tissues  are  chilled.  When  this  method  of  injection  is 
used  it  is  necessary  to  wait  at  least  five  minutes  after  the  gums  have  been  frozen,  so 
that  the  cocain  can  become  most  effective.  The  ethyl  chloride  spray  should  again 
be  used  just  before  extracting  so  as  to  take  advantage  of  the  anesthesia  due  to  cold. 
With  this  latter  method  a  number  of  extractions  can  be  carried  out  without  pain 
which  would  be  only  partially  anesthetic  with  cocain  injections,  and  also  a  0,2  per 
cent,  cocain  or  0.5  per  cent,  tropococain  solutions  can  be  employed.  It  is  not  advis- 
able to  use  solutions  in  the  extraction  of  teeth  which  are  too  weak,  as  the  success  of 
the  method  may  be  sacrificed  by  too  much  dilution. 

Cocain  cataphoresis  has  found  many  supporters  among  the  American  dentists. 
Whether  it  is  possible  to  convey  the  cocain  by  means  of  the  galvanic  current  as  far 


256  LOCAL  ANESTHESIA 

as  the  alveolus  is  questionable.  A  description  of  this  method  as  well  as  the  com- 
plicated apparatus  necessan-  for  its  use  is  described  in  the  work  by  Dorn.  For  the 
special  history  and  literature  of  local  anesthesia  in  dentistry  the  reader  is  referred  to 
the  monographs  of  Thiesing,  Seitz,  and  Laewen. 

In  the  description  given  in  former  editions  of  this  work,  the  introduction  of  supra- 
renin  for  local  anesthesia  in  dental  operations  was  of  incomparable  value.  Dentists 
have  accepted  the  technique  as  described  without  change.  They  have  studied  the 
method  along  anatomical  lines  and  have  occasionally  added  to  their  equipment 
instruments  better  suited  to  their  cases.  The  amount  of  space  given  to  local  anes- 
thesia in  the  dental  literature  of  late  years  is  evidence  of  the  importance  of  this  method 
to  this  specialty.  In  this  work  the  literature  is  referred  to  only  so  far  as  it  concerns 
the  physician.  To  those  who  are  particularly  interested  the  important  work  of 
Buente  and  ]Moral  and  the  monographs  of  G.  Fisher  and  Seidel  can  be  recommended. 

The  Innervation  of  the  Teeth. — The  pulp  and  peridental  membrane  of  the  upper 
jaw  as  well  as  the  labial  side  of  the  periosteum  of  the  alveolar  process  and  the  gums  are 
innervated  by  branches  of  the  infra-orbital  nerve  (Fig.  95).  These  parts  are  supplied 
by  branches  from  the  main  trunk,  partly  before  entering  the  bony  canal  and  partly 
after  entering  this  canal,  and  are  distributed  to  the  bone,  alveolar  process,  or  mucous 
membrane  between  the  antrum  of  Highmore  and  the  anterior  wall  of  the  upper  jaw 
(anterior,  median,  and  posterior  superior  alveolar  nerves),  freely  anastomosing  with 
the  superior  dental  plexus.  The  superior,  posterior,  and  median  alveolar  nerves 
(Fig.  95,  2,  3)  are  located  in  the  beginning  on  the  tuberosity  of  the  maxillary  bone 
and  penetrate  the  upper  jaw  in  the  region  of  the  third  molar  tooth  behind  the  attach- 
ment of  the  zygomatic  process.  The  labial  portion  of  the  gums  is  also  innervated 
by  the  end  branches  of  the  infra-orbital  nerve  after  emerging  from  the  infra-orbital 
foramen.  The  hard  palate,  the  lingual  side  of  the  gums  and  periosteum  are  innervated 
by  the  anterior  palatine  nerve  which  emerges  from  the  major  palatine  foramen  above 
the  third  molar  tooth  and  is  distributed  to  the  soft  parts  overlying  the  hard  palate 
(Fig.  54,  page  214);  also  from  the  end  branches  of  the  nasopalatine  nerve  which 
emerges  anteriorly  from  the  incisive  foramen.  The  pulp  and  peridental  membrane 
are  not  innervated  by  these  nerves. 

The  teeth  of  the  lower  jaw  are  inne^^'ated  in  large  part  by  the  inferior  alveolar 
nerve  which  passes  into  the  bone  at  the  lingula  (Fig.  95) .  This  nerve  gi^'es  off  many 
branches  within  the  bony  canal  forming  the  inferior  dental  plexus  immediately  under- 
lying the  roots  of  the  teeth  (not  shown  in  Fig.  95).  The  pulp  and  peridental  mem- 
brane are  supplied  by  the  dental  rami,  and  the  gums  by  gingival  branches  which 
penetrate  the  bone.  A  larger  branch,  known  as  the  mental  nerve,  leaves  the  bone 
through  the  mental  foramen  which  is  situated  beneath  the  first  and  second  bicuspid 
teeth.     The  smaller  portion  of  the  nerve  contained  within  the  bone  innervates  the 


I 


or  EH  AT  IONS  OX    TlIK   HEAD 


257 


c'aniiu>  and  incisor  teetli.  'V\\v  mental  nerve  supplies  the  skin  of  the  chin  and  the  skin 
and  nuK'ons  membrane  of  the  lower  lij).  The  linji'iial  side  of  the  <2;nms  and  periosteum 
are   innervated   entirely  by  the  lini;iial   nerve  (rami   isthnii  faneinm  and  sublingual 


Fig.  95. — Innervation  of  the  teeth.  (Partly  from  Spalteholz.)  The  lateral  wall  of  the  orbit,  the  outer 
bony  layer  of  the  lower  jaw,  and  parts  of  the  anterior  wall  of  the  upper  jaw  have  been  removed.  1,  infra- 
orbital nerve;  2,  branches  of  the  superior  posterior  alveolar  nerve;  3,  branches  of  the  superior  median 
alveolar  nerve;  4,  branches  of  the  superior  anterior  alveolar  nerve;  5,  sphenopalatine  ganglion  and  palatine 
nerves;  6,  mucous  membrane  of  the  lateral  wall  of  the  antrum;  7,  inferior  alveolar  nerve;  8,  mental  nerve. 


nerve).  In  the  median  line  the  inferior  alveolar,  mental  and  lingual  nerves  overlap 
one  another  more  or  less.  It  is  also  to  be  observed  that  the  buccinator  nerve 
to  some  extent  innervates  the  labial  side  of  the  gums  of  the  last  molar  tooth. 

Methods  to  be  Used  in  Operations  upon  the  Upper  Teeth.— It  is  important  to 
know  that  the  dental  plexus,  formed  from  the  nerve  fibers,  lies  above  the  roots  of  the 
17 


258 


LOCAL  ANESTHESIA 


teeth  just  below  the  thin  anterior  and  lateral  wall  of  the  upper  jaw  where  they  can 
be  readily  anesthetized,  and  that  the  posterior  superior  alveolar  nerves  are  just 
beneath  the  mucous  membrane  of  the  tuberosity  of  the  maxilla  where  they  can  be 
injected  before  entering  the  bone,  for  which  reasons  the  injections  of  the  labial  side 
are  by  far  the  most  important  in  operations  on  the  upper  jaw.  The  technique  of  this 
injection  has  undergone  characteristic  changes  in  the  course  of  time.  One  of  the 
first  publications  in  reference  to  cocain  anesthesia  for  the  extraction  of  teeth  was 
that  of  Witzel.  In  1886  he  injected  the  fold  of  mucous  membrane  high  up  in  the  jaw, 
at  its  point  of  reduplication,  using  a  20  per  cent,  cocain  solution,  which  was  the  one 
most  commonly  used  at  that  time.  Later,  when  much  weaker  solutions  were  used 
for  injection,  the  dilution  exerted  less  distal  effect  upon  the  nerves  in  the  bones,  and 
it  became  necessary  to  infiltrate  the  gums,  periosteum,  and  alveolar  process  sur- 
rounding the  tooth  to  be  extracted  with  cocain  solution.  This  procedure  is  not 
necessary  today  because  we  have  solutions  equally  as  effective  as  those  containing 
20  per  cent,  cocain,  for  which  reason  we  can  again  return  to  the  simple  technique 
of  Witzel. 


Oblique  line 
Figs.  96  and  97. — Submucous  injections  for  the  extraction  of  teeth. 


The  injections  on  the  anterior  surface  of  the  jaw  are  made  in  the  following  manner: 
The  lip  and  cheek  are  drawn  away  from  the  upper  jaw  so  that  the  mucous  membrane     -i 
at  the  point  of  reduplication  forms  a  right  angle  with  the  alveolar  process.     The     ] 
syringe  is  held  horizontally,  the  needle  is  inserted  in  a  horizontal  direction  into  the      ] 


OPERATIONS  ON   THE  HEAD  259 

reduplicating  fold  above  the  roots  of  the  teeth  between  the  mucous  membrane  and  the 
l^eriosteum  (Fig.  9(i).  For  rendering  the  incisor  and  canine  teeth  insensitive  the 
])oint  for  injection  lies  next  to  the  frenum;  for  the  bicuspid  and  first  molar  teeth, 
alH)\e  the  roots  behind  the  attachment  of  the  zygomatic  process  under  the  mucous 
membrane  covering  the  maxillary  tubercle  (Fig.  97). 

In  case  it  is  desired  to  anesthetize  one  tooth,  the  needle  is  passed  from  a  point 
cxtrresponding  to  the  tooth  in  front  to  the  tooth  behind  the  one  to  be  anesthetized. 
In  case  several  teeth  of  the  upper  jaw  are  to  be  rendered  insensitive  a  strip  of  tissue 
should  be  injected  continuously  from  the  points  mentioned  as  far  as  the  maxillary 
tubercle  of  the  same  side,  injections  being  carried  out  from  1,  2,  or  3  points.  Follow- 
ing the  injection  the  reduplicating  fold  swells.  Immediately  upon  the  withdrawal 
of  the  needle  the  point  of  injection  should  be  closed  with  the  finger  and  the  anesthetic 
distributed  over  the  anterior  surface  of  the  upper  jaw  by  light  massage.  The  most 
suitable  anesthetic  for  this  purpose  is  a  2  per  cent,  novocain-suprarenin  solution, 
or,  according  to  Fischer,  a  1.5  per  cent,  solution;  for  one  or  two  teeth  2  to  3  c.c.  will 
be  necessary,  for  the  entire  half  of  the  upper  jaw  5  to  10  c.c.  should  be  used.  For 
the  extraction  of  many  teeth  it  is  advisable  to  inject  the  anterior  surface  of  the  jaw 
and  maxillary  tubercle  from  the  cheek,  as  w^as  described  on  page  248.  Anesthesia  is 
complete  in  about  five  minutes,  very  rarely  sooner,  but  sometimes  later,  and  con- 
sists in  complete  anesthesia  of  the  labial  portion  of  the  gum  and  periosteum  in  the 
region  of  the  tooth  or  the  entire  half  of  the  upper  jaw,  depending  upon  the  extent 
of  the  injection.  There  will  also  be  complete  anesthesia  of  the  pulp  and  peridental 
membrane.  This  injection  alone  is  sufficient  for  operations  upon  the  pulp  and  den- 
tin, also  for  the  removal  of  roots  and  other  operations  upon  the  anterior  surface 
of  the  alveolar  process.  The  end  branches  of  the  infra-orbital  nerve  outside  of  the 
bone  are  readily  made  insensitive  if  they  are  directly  surrounded  by  the  anesthetic 
solution. 

For  the  extraction  of  the  upper  teeth  it  is  necessary  to  anesthetize  the  lingual  side 
of  the  gums  and  periosteum.  For  the  extraction  of  a  single  tooth  1  c.c.  of  a  2 
per  cent,  novocain-suprarenin  solution  should  be  injected  beneath  the  hard  palate 
adjoining  the  diseased  tooth.  For  anesthetizing  the  entire  half  of  the  hard  palate 
in  the  extraction  of  many  teeth  see  page  214.  The  blocking  of  the  entire  maxillary 
nerve  should  be  considered  w^hen  operations  for  suppurative  processes  of  the  alveolar 
process  would  render  the  injection  in  its  immediate  neighborhood  dangerous.  Injec- 
tions for  dental  operations  at  the  base  of  the  skull  are  otherwise  unnecessary  and  are 
not  to  be  recommended  for  dental  work  owing  to  the  occurrence  of  hematomata. 

Operations  upon  the  Teeth  of  the  Lower  Jaw. — Injections  under  the  mucous  mem- 
brane of  the  alveolar  process  of  the  lower  jaw  can  only  be  successfully  performed  in 
connection  with  the  incisor  and  canine  teeth.    Posteriorly  the  bone  is  much  too  thick 


260  LOCAL  ANESTHESIA 

for  the  anesthetic  to  exert  its  effect  upon  the  nerves  of  the  pulp,  and  Hngual  injections 
are  only  made  with  difficulty.  For  these  reasons  it  is  advisable  to  block  the  alveolar 
and  lingual  nerves  at  the  lingula  (page  220),  in  this  way  producing  complete  anes- 
thesia of  both  sides  of  the  gums  and  periosteum  of  the  bone,  and  the  pulp  as  far 
forward  as  the  canine  tooth.  In  operations  upon  the  last  molar  tooth  it  is  advisable 
to  make  additonal  injections  into  the  labial  side  of  the  gum  so  as  to  block  any 
branches  from  the  buccinator  nerve.  In  connection  with  operations  upon  the 
incisor  teeth,  which  are  doubly  innervated  by  the  overlapping  of  the  inferior  alveolar 
nerve,  it  is  advisable  to  use  a  second  injection  besides  that  at  the  lingula  which  has 
been  described  by  G.  Fischer  as  follows:  The  lower  lip  is  drawn  out  and  the  needle 
is  inserted  in  the  fold  of  reduplication  beneath  the  canine  tooth  and  passed  along  the 
anterior  surface  of  the  lower  jaw  to  the  mental  fossa.  This  fossa  usually  contains 
numerous  foramina  which  permit  the  injected  fluid  to  reach  the  interior  of  the  jaw. 
Injection  is  made  during  the  entire  passage  of  the  needle,  but  the  bulk  of  the  solution, 
about  1  c.c.  of  a  2  per  cent,  novocain-suprarenin  solution,  is  injected  in  the  region  of 
the  mental  fossa.  When  bilateral  extractions  or  operations  are  to  be  performed, 
the  lingula  is  injected  on  both  sides,  which  will,  of  course,  render  the  injection  of  the 
anterior  surface  of  the  lower  jaw  unnecessary. 

The  fear  expressed  by  Buente  and  Moral  of  a  disturbance  of  salivary  secretion 
due  to  the  blocking  of  the  lingual  nerve  has  never  been  reported,  nor  has  injury  to 
a  patient's  tongue  anesthetized  in  this  way  been  observed,  if  they  have  been  pre- 
viously cautioned.  It  might  be  stated  that  the  above  method  of  anesthesia  for  the 
entire  alveolar  process  of  the  upper  and  lower  jaw,  either  unilaterally  or  bilaterally, 
should  always  be  the  anesthetic  of  choice  in  all  other  operations  upon  the  ah'eolar 
process. 

A  few  words  may  be  said  regarding  secondary  hemorrhage  following  the  use  of 
suprarenin  in  the  extraction  of  teeth.  Personally,  in  over  1000  extractions  the 
author  has  never  experienced  this  complication  and  does  not  believe  that  suprarenin 
can  cause  a  serious  secondary  hemorrhage  which  would  not  have  occurred  without  its 
use;  the  hemorrhage,  if  it  occurs,  has  been  merely  delayed  by  the  suprarenin.  Second- 
ary hemorrhage  following  the  extraction  of  teeth  can  be  prevented  if  the  alveolar 
process  is  packed  with  iodoform  gauze  for  a  day  or  two,  as  has  been  advised  by  Roemer. 
From  a  surgical  stand-point  this  would  seem  to  be  the  correct  way  of  handling  these 
cases.  Where  there  are  large  cavities  left  in  the  alveolar  process  after  extraction 
packing  must  naturally  be  done.  Today  the  majority  of  dentists  take  the  stand  that 
general  anesthesia  should  not  be  used  for  dental  operations.  This  question  has  been 
investigated  by  Wolfram  in  the  various  German  dental  institutions  where  local  anes- 
thesia is  taught  and  he  found  that  general  anesthesia  was  very  rarely  used.  Knowledge 
of  the  application  of  local  anesthesia  is  one  of  the  leading  questions  of  the  day.    The 


3 

I 


OPERATIONS  ON   THE  HEAD  261 

only  general  anesthetic  which  enters  into  competition  with  local  anesthesia  for  the 
short  and  simple  operation  of  extraction  of  a  tooth  is  the  ether  or  ethyl  chloride 
("ransch")  drunk,  as  there  is  practically  no  danger  associated  with  this  form  of  anes- 
thesia. In  cases  that  are  more  or  less  complicated,  that  require  more  than  a  minute 
for  their  performance  and  that  can  be  better  carried  out  slowly,  there  is  no  general 
anesthetic  which  compares  with  local  anesthesia.  The  extraction  of  many  teeth 
under  ether,  chloroform,  or  ethyl  ])romide  cannot  be  countenanced  by  the  physician. 


OPERATIONS    ON    THE   PALATE.     NASOPHARYNGEAL   FIBROMATA. 

Anesthesia  of  the  soft  and  hard  palate  from  4  points  of  entrance  for  the  needle 
was  described  on  page  214.  For  a  simple  incision,  infiltration  of  the  proposed  line  of 
incision  with  0.5  per  cent,  novocain-suprarenin  solution  is  suggested.  The  removal 
of  the  hard  palate  requires  a  bilateral  blocking  of  the  maxillary  nerve.  Once  again, 
the  most  cautious  use  of  suprarenin  is  advised  in  plastic  operations  on  the  palate. 
The  suprarenin  anemia  simplifies  this  operation  to  such  an  extent  that  it  is  scarcely 
permissible  to  dispense  with  it,  but,  as  has  already  been  stated  on  page  238  in  reference 
to  plastic  operations  in  general,  the  operator  must  guard  against  nutritive  disturb- 
ances in  the  separated  Langenbeck  flap  by  the  cautious  use  of  suprarenin. 

It  is  advisable  in  making  these  injections  to  use  at  most  but  half  the  quantity  of 
suprarenin  that  is  usually  advised  for  operations  in  general,  for  which  reason  the 
solutions  should  not  be  prepared  from  the  tablets.  In  other  operations  upon  the 
palate  this  precaution  is  unnecessary.  Extirpation  of  nasopharyngeal  fibromata 
has  assumed  an  entirely  different  phase  since  the  introduction  of  local  anesthesia 
and  suprarenin  anemia;  they  can  now  be  removed  with  practically  no  hemorrhage. 
A  case  in  which  a  tumor  of  this  nature  was  removed  under  local  anesthesia  by  first 
performing  a  temporary  resection  of  the  upper  jaw  according  to  the  method  of  Kocher 
is  described  on  page  243.  Simple  cases,  having  a  definite  pedicle  extending  from  the 
base  of  the  skull,  can  readily  be  completed  by  incising  the  soft  palate.  Local  anesthesia 
with  suprarenin  anemia  limits  the  indications  for  preliminary  operations  in  com- 
plicated cases. 

This  may  be  explained  by  citing  a  history:  ^lay  7,  1904,  a  man,  aged  eighteen 
years,  had  a  hard  fibroma  attached  by  a  broad  base  to  the  base  of  the  skull  in  the 
nasopharyngeal  space.  The  operation  was  begun  for  physical  reasons  under  general 
anesthesia  with  the  head  dependent.  The  hard  and  soft  palate  were  infiltrated  wdth 
a  0.1  per  cent,  cocain  solution  with  the  addition  of  suprarenin;  general  anesthesia 
was  then  discontinued.  The  soft  palate  was  split  in  the  middle  line  without  hemor- 
rhage, under  guidance  of  the  finger  in  the  nasopharyngeal  space;  a  long  needle  was 


262  LOCAL  ANESTHESIA 

passed  through  the  left  nasal  opening  to  the  base  of  the  tumor  and  the  same  solution 
was  injected.  After  a  few  minutes  the  tumor  was  removed  with  curved  scissors 
without  hemorrhage.  The  palate  was  closed  by  suture,  the  nasopharyngeal  space 
and  nose  were  tamponed,  no  secondary  hemorrhage  following,  the  healing  being  very 
prompt.  In  two  other  cases  the  author  removed  large  nasopharyngeal  fibromata  in 
this  manner;  in  these  cases,  of  course,  0.5  per  cent,  novocain-suprarenin  solution 
was  injected  instead  of  the  cocain  solution. 


OPERATIONS   UPON    THE    TONGUE,    FLOOR   OF    THE   MOUTH    AND 
TONSILS. 

The  anterior  two-thirds  of  the  tongue  and  the  floor  of  the  mouth  are  innervated 
by  the  lingual  nerve,  which  can  be  readily  blocked  by  injections  at  the  lingula  (page 
220).  The  posterior  portion  of  the  tongue,  tonsillar  region  and  the  pharynx  are 
supplied  by  the  glossopharyngeal  nerve;  the  soft  palate  and  anterior  portion  of  the 
hard  palate  are  supplied  by  the  maxillary  nerve.  The  region  above  the  epiglottis 
is  supplied  by  the  superior  laryngeal  nerve. 

Anesthesia  of  the  tongue  and  the  floor  of  the  mouth  by  blocking  the  lingual  nerve 
does  not  produce  the  important  suprarenin  anemia;  for  which  reason  in  all  operations 
upon  these  parts,  as  well  as  the  palate  and  pharynx,  infiltration  and  circuminjection 
are  necessary. 

Hirschel  has  recently  reported  a  method  of  blocking  the  glossopharyngeal  and 
vagus  nerves  at  the  base  of  the  skull.  He  inserts  a  needle  between  the  maxillary 
articulation  of  the  lower  jaw  and  the  mastoid  process,  passing  the  styloid  process 
in  the  direction  of  the  occipital  condyle  to  a  depth  of  3  to  4  cm.  and  injects  in  this 
region  10  to  15  c.c.  of  a  2  per  cent,  novocain-suprarenin  solution.  The  glossopharyn- 
geal, vagus  and  accessory  lie  near  one  another  at  the  base  of  the  skull  in  a  connective 
tissue  sheath  which  includes  the  internal  jugular  vein  and  internal  carotid  artery. 
A  successful  blocking  of  the  glossopharyngeal  nerve  is  readily  recognized  by  a  paralysis 
of  the  recurrent  laryngeal  and  the  accessory  nerves.  This  method  of  Hirschel 
remains  to  be  tested  as  to  its  certainty  and  freedom  from  danger.  In  operations  in 
the  pharynx  and  region  of  the  tonsil  the  local  circuminjection  should  be  performed 
owing  to  the  effect  of  the  anemia  produced.  Sensation  in  these  parts  is  not  very 
pronounced;  at  any  rate  the  failure  to  block  the  glossopharyngeal  and  vagus  nerves 
has  never  been  reported  to  cause  any  disturbance  on  the  part  of  patients  in  excision 
of  tonsils  or  pharyngeal  carcinomata.  The  latter  was  performed  either  through  the 
neck  from  without  or  following  a  temporary  separation  of  the  jaw.  Whether  the 
trunk  of  the  vagus,  after  branching  of  the  auricular  nerve,  possesses  pain  sense  is 


OPERATIONS  ON    Till':   HEAD 


2()3 


very  (iiR'stioiiahlc.  'I'lic  point  of  most  importance,  liowcxer,  is  tiie  anesthetizin*:;  of 
the  operative  field  to  such  an  extent  as  to  ])ermit  of  the  free  exposure  of  the  pharynx. 
Pharyngeal  reflexes  can  be  allayed  by  api)lications  of  alypin-suprarenin  solutions. 
As  soon  as  the  pharynx  becomes  accessible,  the  anesthesia  can  be  completed  by 
submucous  injections.  The  blocking  of  the  superior  laryngeal  nerve  will  be  described 
in  the  following  chai)ter. 

Operations  upon  the  Tongue  without  a  Preliminary  Operation. — We  will  take  as  an 
exami)le  the  remo\al  of  a  small  tumor  from  the  lateral  portion  of  the  tongue  or  from 
its  anterior  portion,  or  the  removal  of  sections  for  microscopic  examination.  For 
this  purpose  a  small  wheal  is  injected  upon  the  surface  of  the  tongue  with  a  0.5  per 
cent,  novocain-suprarenin  solution.  A  needle  is  then  passed  through  the  tongue 
as  far  as  the  mucous  membrane  of  its  under  surface.  This  tract  is  infiltrated  wdth 
the  same  solution,  after  which  a  traction  suture  is  passed  through  the  anesthetized 
area  so  the  tongue  can  be  drawn  forward  and  fixed.  The  diseased  area  is  now^  circularly 
injected  with  0.5  per  cent,  novocain-suprarenin  solution,  after  which  the  tumor  can 
be  removed  without  pain  or  hemorrhage  and  the  wound  sutured. 


In  case  the  disease  is  more  extensive,  this  circuminjection  is  dispensed  with  and  in 
its  place  the  entire  tongue  and  floor  of  the  mouth  are  rendered  anesthetic  and  anemic 
])y  the  following  procedure:  One  point  of  entrance  is  marked  by  a  wheal  under  the 
chin  in  the  median  line  immediately  over  the  hyoid  bone.  The  left  finger  is  then 
passed  above  the  epiglottis  to  the  base  of  the  tongue  in  the  same  manner  as  when 


264 


LOCAL  ANESTHESIA 


performing  intubation.  From  this  point  a  long  needle  is  passed  toward  the  tip  of 
the  finger  infiltrating  this  area  (Fig.  98) ;  the  needle  is  then  passed  in  various  direc- 
tions, first  in  the  median  line,  then  more  toward  the  right  and  left,  and  finally  as  far 
laterally  as  the  lower  jaw.  This  separates  the  tongue  and  floor  of  the  mouth  from 
their  blood  and  nerve  supply  by  an  infiltrated  barrier.  For  this  injection  50  c.c.  of 
0.5  per  cent,  novocain-suprarenin  solution  is  necessary.  The  tongue  and  floor  of 
the  mouth  will  become  insensitive  and  anemic.  The  tongue  can  now  be  drawn  out 
and  the  operation  completed.    Injections  at  the  lingula  are  not  necessary. 

Minor  Operations  on  the  Floor  of  the  Mouth. — Small  cysts  (ranula)  or  benign 
timiors  of  the  floor  of  the  mouth  should  be  injected  from  without  from  a  point  under 
the  chin.  The  needle  is  guided  by  the  left  index  finger  placed  in  the  mouth,  and  the 
area  is  injected  with  0.5  per  cent,  novocain-suprarenin  solution.  Large  cysts  in 
the  median  line  of  the  floor  of  the  mouth  which  cause  a  bulging  in  the  chin  region 
are  better  extirpated  from  without.  This  can  be  done  after  a  bilateral  blocking  of 
the  lingual  nerve  at  the  lingula.  It  will  then  only  be  necessary  to  circuminject  the 
operative  field  in  the  usual  manner. 


Fig.  99. — Points  of  injection  for  tonsillectomy. 
(After  Heymann.) 


Fig.  100. — Circuminjection  for  median  '• 
section  of  the  jaw.  3,  point  of  injection  , 
over  the  hyoid  bone.  t 


Local  Anesthesia  for  Tonsillectomy. — Anesthesia  for  tonsillotomy  is  usually  not 
necessary,  but  the  operation  of  tonsillectomy,  as  performed  today  by  the  specialists 
in  this  field,  requires  anesthesia.  For  anesthesia  of  this  region  the  anterior  and  pos- 
terior pillars  of  the  fauces  should  be  infiltrated  from  several  points  (Fig.  99).  This 
area  as  well  as  the  tissues  lateral  to  the  tonsils  is  freely  infiltrated  with  10  to 
15  c.c.   of  a  0.5  novocain-suprarenin   solution.     For  anesthesia  of  the  pharyngeal 


OPERATIONS  ON   THE  HEAD 


265 


ton.sil  Riiprecht  advises  the  a])i)lic'ation  of  tampons  saturated  with  11)  ])er  cent,  alypin- 
suprarenin  sohition.  These  a])pHeations  are  made  hy  means  of  a  sound  passed  throuj^h 
the  nasal  canal. 

Radical  Operations  for  Carcinoma  of  the  Tongue,  Floor  of  the  Mouth  and  Tonsillar 
Region. — The  anesthesia  is  begun  by  a  l)ilateral  blocking  of  the  lingual  and  inferior 
aheolar  nerves  at  the  lingula  (page  220)  and  completed  by  an  injection  as  is  shown 
in  Fig.  98,  In  case  the  operative  field  extends  to  the  pillars  of  the  fauces,  tonsillar 
region,  or  lateral  pharyngeal  wall,  these  areas  must  be  injected  from  below  and  behind 


Fig.  101. — Excision  of  the  base  of  the  tongue  and  left  tonsil  for  carcinoma.  The  lower  jaw  is  cut,  the 
tongue  drawn  to  the  right.  The  epiglottis  is  seen  in  the  depths  of  the  wound  at  the  completion  of  the 
operation. 


with  0.5  novocain-suprarenin  solution.  A  blocking  of  the  maxillary  ner\-e  is,  as  a 
rule,  not  required.  It  wdll  now  be  necessary  to  anesthetize  the  parts  for  the  preliminary 
operation,  which  consists  of  a  transverse  splitting  of  the  cheek  as  described  on  page 
238.  The  method  of  circuminjection  for  a  median  section  of  the  lower  jaw  is  shown 
in  Fig.  100.  Point  3  indicates  where  the  needle  must  be  passed  for  infiltrating  the 
base  of  the  tongue.  For  the  circuminjection  30  c.c.  of  a  0.5  per  cent,  novocain- 
suprarenin  solution  is  necessary. 

The  operation  can  now  be  performed  without  pain  or  hindrance  from  hemorrhage. 
Peuckert  and  the  author  have  reported  13  cases  of  excision  of  the  tongue,  extirpation 


266  LOCAL  ANESTHESIA  $ 

of  the  floor  of  the  mouth  in  connection  with  resections  of  portions  of  the  lower  jaw, 
and  extirpation  of  carcinoma  of  the  tonsils,  with  this  method  of  anesthesia.    Fig.  101 
shows  one  of  our  patients  during  the  operation.    What  has  been  said  already  wdth     i 
reference  to  resections  of  the  upper  jaw  holds  for  operations  in  the  mouth;  that  is,     ' 
local  anesthesia  has  changed  completely  the  appearance  of  these  patients  during     ! 
operation.    It  has  simplified  the  operation,  which  can  be  carried  out  in  a  much  cleaner     , 
manner  and  all  danger  of  aspiration  pneumonia  is  eliminated.    We  had  only  two  post- 
operative lung  complications  in  the  13  patients  operated  upon  under  local  anesthesia 
in  connection  with  susprarenin  anemia.     A  large  number  of  cases  of  carcinoma  of 
the  mouth,  in  which  formerly  a  median  section  of  the  lower  jaw  was  necessary  as  a 
preliminary  operation,  can  now  be  operated  upon  with  as  much  ease  by  the  simple     i 
section  of  the  cheek.  j 


CHAPTER    XII. 
OPEUATIOXS   OX  THE   XECK. 


Bier  and  ^NIadelung  have  pointed  out  the  possibility  of  performing  major 
operations  of  all  kinds  upon  the  neck  under  local  anesthesia.  Bier  lays  special  stress 
ui)on  its  use  for  thyroidectomy  and  extirpation  of  the  larynx.  IMadelung  states  that 
lie  has  for  many  years  preferred  a  1  per  cent,  novocain-suprarenin  solution  for  local 
anesthesia  in  all  major  operations,  such  as  thyroidectomies,  removal  of  glands, 
resection  and  extirpation  of  the  larynx,  pharynx  and  esophagus. 


Fig.   102.— The  sensor 


,  cutaneus  colli; 


The  soft  structures  of  the  front  of  the  neck  are  supplied  b}-  the  anterior  branches 
of  the  second,  third,  and  fourth  cervical  nerves,  whose  terminal  branches,  the  auricu- 
laris  magnus,  cutaneus  colli,  and  supraclavicular,  come  to  the  surface  at  the  pos- 
terior edge  of  the  sternocleidomastoid  muscle.  Pain  in  the  larynx  and  esophagus  is 
probably  transmitted  only  through  the  cervical  ner\-es  (Fig.  102).  On  the  other  hand 
it  is  quite  improbable  that  any  i)ain  is  transmitted  from  the  neck  by  the  vagus. 
The  mucous  membrane  of  the  esoi)hagus  is  devoid  of  any  sensibility. 


268 


LOCAL  ANESTHESIA 


A  subcutaneous  and  subfascial  injection  along  the  posterior  edge  of  the  sterno- 
cleidomastoid merely  renders  the  skin  of  the  neck  insensitive,  which  practically  is 
of  no  value.  Complete  anesthesia  of  the  region  supplied  by  the  specified  nerves 
is  only  obtained  by  anesthetizing  the  nerves  as  they  leave  the  spinal  column. 

Kappis  recently  reported  that  he  had  succeeded  in  blocking  the  cervical  nerves 
just  as  they  leave  the  foramina  of  the  cervical  vertebrae,  and  thus  was  able  to  anes- 
thetize the  whole  cervical  and  brachial  plexus.  He  introduces  the  needle  from  the 
back,  laterally  along  the  spinous  processes  to  the  transverse  processes  of  the  cervical 
vertebrae  and  even  beyond  them  for  another  1  to  1.5  cm.  forward,  and  injects  1.5 
per  cent,  novocain-suprarenin  solution. 


Fig.   103.— Line  of  the  t 


id  h,  point.s  of  entrance  for  the  needle. 


Heidenhain's  method  for  major  operations  of  the  neck  is  to  inject  from  the 
side  and  freely  infiltrate  the  region  of  the  third  to  the  fifth  cervical  vertebra, 
where  the  nerves  concerned  lie  close  together,  using  a  0.5  per  cent,  novocain- 
suprarenin  solution.  This  is  accomplished  in  the  following  manner:  A  line  is 
drawn  on  the  side  of  the  neck  indicating  the  location  of  the  transverse  processes  of 
the  cervical  vertebra.  This  line  begins  above,  immediately  behind  the  tip  of  the 
mastoid  process,  and  passes  slightly  backward  from  the  posterior  edge  of  the  sterno- 
cleidomastoid muscle  forming  an  acute  angle  with  it.     The  transverse  process  of 


OPERATIONS  ON  THE  NECK  2()9 

the  atlas  (first  cervical  vertebra)  is  felt  under  the  mastoid  process,  and  lower  the 
transverse  process  of  the  sixth  cervical  vertebra  (tuberculum  carotideum)  is  felt 
as  a  rule.  This  indicates  the  line  of  the  transverse  processes  in  which  the  two  points 
of  injection  a  and  b  (Fig.  103)  should  lie.  The  upper  injection  should  be  made  behind 
the  angle  of  the  jaw  in  a  line  continuous  with  its  lower  edge.  The  second  injection 
should  be  made  on  a  level  with  the  prominence  of  the  thyroid  cartilage.  From  these 
two  points  the  needle  is  directed  to  the  transverse  processes  of  the  cervical  vertebrse 
wliich  must  be  felt  with  the  needle,  and  all  tissue  layers  between  the  process  and  the 
skin  are  thoroughly  infiltrated  with  a  0.5  per  cent,  novocain-suprarenin  solution, 
according  to  the  diagram  of  Fig.  29  (page  189).  For  this  injection  about  30  to  40  c.c. 
will  be  required.  This  injection  does  not  come  in  contact  with  the  bloodvessels  of  the 
neck,  but  further  injections  into  the  field  of  operation  will  always  be  necessary.  By 
making  this  injection  on  both  sides  complete  anesthesia  of  all  the  organs  in  the  front 
of  the  neck  is  obtained.  Whenever  the  occasion  demands  the  superior  laryngeal 
ne^^-e  should  also  be  blocked  (see  below).  If  the  operation  extends  upward  into  the 
field  of  the  third  branch  of  the  trigeminus,  a  bilateral  injection  at  the  lingula  or  a 
direct  infiltration  of  the  floor  of  the  mouth  becomes  necessary. 

In  this  manner  a  very  definite  type  of  anesthesia  is  obtained  for  all  major  throat 
operations.  The  injection  for  the  transverse  processes,  as  described,  forms  the  basis 
for  all  circuminjections. 

The  Extirpation  of  Lymphatic  Glands  and  Tumors  of  the  Neck.— We  will  begin 
with  the  most  extensive  operation,  one  that  taxes  local  anesthetic  measures  to  the 
utmost,  viz.:  the  total  extirpation  of  all  the  fatty  tissue  of  the  neck,  including  the 
lymphatic  glands  and  submaxillary  salivary  gland  which  lie  under  the  jaw  and 
surround  the  large  bloodvessels,  as  a  preliminary  to  operation  for  carcinoma  of 
the  lower  lip  and  oral  cavity. 

Fig.  104  shows  the  diagram  for  unilateral  and  bilateral  injections;  a-b  and  c  d  are 
the  lines  of  injection  which  extend  along  the  transverse  processes  of  the  cervical  ver- 
tebrae. The  subfascial  and  subcutaneous  tissues  in  the  field  of  operation  are  injected 
l)y  means  of  long  needles,  parallel  to  the  outer  skin.  When  the  submaxillary  salivary 
gland  is  to  be  removed,  the  infiltration  is  made  through  the  points  of  entrance  marked 
on  the  edge  of  the  jaw,  because  this  region  is  supplied  by  the  trigeminus.  For  this 
injection  100  to  125  c.c.  of  a  0.5  per  cent,  novocain-suprarenin  solution  will  be  neces- 
sary. Patients  experience  no  pain  during  this  operation,  and  the  procedure  is 
greatly  facilitated  by  the  suprarenin  anemia.  Fig.  105  shows  one  patient  after  a 
unilateral,  and  Fig.  106  one  after  a  bilateral  extirpation  of  glands.  Disturbances  of 
the  phrenic  nerve  have  never  been  reported  in  these  bilateral  injections  of  the  trans- 
verse processes  of  the  cervical  vertebra,  but  theoretically  such  disturbance  might 
be  possible. 


270 


LOCAL  ANESTHESIA 


Fig.   10-4. — Circuminjection  for  operations  on  the  neck. 


'AM 


■^ 


f 


Fig.  105. — Removal  of  the  left  submaxillary 
salivary  gland,  submental  and  lymphatics  of  the 
neck  under  local  anesthesia  for  carcinoma  of  the 
base  of  the  tongue  and  left  tonsil.  The  left  .jugular 
vein  was  resected. 


Fig.    106. — Dissection  of  the  neck    for  com- 
plete  removal  of  the   lymphatics  of   the   neck   : 
and    the    submaxillary    salivary    gland    under 
local  anesthesia  for  carcinoma  of  the  tongue. 


OI'E  RAT  IONS  ()\    THE   XECK 


271 


It  is  interesting  to  note  that  no  pain  is  felt  in  resection  of  the  vagns,  ahh()ii.-;h  it 
is  not  affected  by  the  injection. 

The  only  difficulties  encountered  in  using  the  described  method  of  anesthesia  will 
be  in  extirpation  of  masses  of  lymphatic  glands  and  tumors  which  have  developed 
posteriorly  over  the  edge  of  the  sternocleidomastoid  beyond  the  line  of  transverse 
processes  and  which  cover  the  cervical  plexus.  In  such  cases  Kappis  states  that  good 
results  will  be  ol)tained  by  making  the  injection  from  behind,  along  the  transverse 
processes.     Naturally  the  whole  surface  of  the  tumor  must  also  be  circuminjected. 

Some  circumscribed  and  movable  tumors  or  masses  of  lymphatic  glands  can  be 
injected  in  a  pyramidal  manner  according  to  the  plan  in  Fig.  28,  provided  no  large 
vessels  are  encountered.     The  injection  is  more  easily  made  if  the  tumor  is  lifted  uj). 

In  the  following  operations  the  lines  of  injection  represent  at  the  same  time  a 
section  of  those  usefl  for  the  whole  front  surface  of  the  neck: 


Fig.   107. — Injection  for  ligation  of  the  super 


Ligation  of  the  External  Carotid  or  Superior  Thyroid  Arteries. — The  essential 
point  of  this  injection  is  to  infiltrate  a  strij)  of  connective  tissue  in  the  line  of  the 
transverse  processes  (Fig.  107).  The  field  of  operation  is  subfascially  and  subcuta- 
neously  injected  in  a  rectangular  or  triangular  form  by  long  neerlles.  The  form  of 
the  injection  naturally  depends  on  the  incision  to  l)e  made. 

Ligation  of  the  Common  Carotid  or  of  Inferior  Thyroid  Arteries.— In  Basedow's 
disease  an  extracapsular  ligation  of  the  inferior  thyroid  artery  according  to  de  Quer- 
vain  is  advised  in  every  case.    The  line  of  injection  is  similar  to  the  one  in  Fig.  107, 


272 


LOCAL  ANESTHESIA 


but  lies  correspondingly  lower.     Here,  too,  the  main  point  is  the  infiltration  of  the 
line  of  transverse  processes. 

Suprahyoid  Pharyngotomy. — The  author  performed  a  unilateral  suprahyoid  pharyn- 
gotomy  in  one  case  for  extirpation  of  a  spindle-celled  sarcoma  which  was  situated  under 
the  submucosa  of  the  left  tonsil;  the  diagram  of  injection  corresponded  with  the  left 
upper  quarter  of  Fig.  104.  The  floor  of  the  mouth  was  also  infiltrated  through  the 
points  of  injection  marked  on  the  border  of  the  jaw,  as  in  this  operation  the  area 
supplied  b}^  the  trigeminus  is  invaded;  the  operation  was  absolutely  painless  and 
bloodless. 


Fig.   108. — Thyroidectomy  with  excision  of  the  right  lobe  and  isthmus. 


Thyroidectomy. — In  this  operation  five,  and  in  cases  of  large  goitre  six,  points  of  , 
injection  are  necessary  as  shown  in  Fig.  109.  Points  1  and  2  correspond  with  the  | 
line  of  the  transverse  processes  and  these  points  serve  for  infiltration  as  far  as  the  j 
transverse  processes.  The  other  points  are  joined  by  subfascial  and  subcutaneous 
lines  of  injection,  and  are  reached  by  long  needles.  In  the  lines  3,  4,  and  5  these  I 
subfascial  injections  must  be  given  generously  in  order  to  be  sure  of  excluding  the  I 
innervation  from  the  other  side.     From  75  to  125  c.c.  of  0.5  per  cent,  novocain-  1 


OPKRATfOXS  OX   THE   SFAK 


273 


suprareiiin  solution  will  he  necessary,  (leixMidiiif;-  of  coursr  upon  the  size  of  tlic  field 
of  operation.  When  both  halves  of  the  thyroid  gland  are  to  be  removed  at  the  same 
time,  the  injection  is  made  throughout,  as  shown  in  Fig.  109.  It  is  self-evident  that 
the  injection  need  not  extend  so  far  as  the  inframaxillary  border.  There  must  be  a 
bilateral  injection  of  the  line  of  the  transverse  processes. 

This  method  is  preferred  to  that  of  von  Hackenbruch,  who  injects  close  to  the 
tumor,  because  there  is  no  contact  with  the  large  vessels  of  the  neck  or  with  the 
thyroid  veins,  and  because  it  can  also  be  employed  in  malignant  cases. 


^^^HH^^^ 

'^^^1 
A 

i 

Hp^'-^-^r 

t 

^ 

1           >"" 

F 

^ 

Fig.  109. — Thyroidectomy  with 


of  the  right  lobe  and  isthn 


Anxious  patients  are  usually  given  scopolamin-morphin  (Bier).  Hackenbruch 
prepares  the  patient  by  giving  20  to  30  drops  of  tincture  of  opium,  because  he  has 
found  that  morphin  given  before  thyroidectomy  is  apt  to  cause  vomiting.  Axhausen 
has  made  the  same  observation.  Sensible  patients  need  no  opiate,  since  the  operation 
causes  no  pain. 

Formerly  there  was  much  reticence  about  using  local  anesthesia  for  thyroidec- 
tomy because  of  the  incomplete  anesthesia  which  most  surgeons  obtained.  This 
has  been  overcome  by  circuminjecting  the  goitre  in  the  above-mentioned  manner. 
18 


274 


LOCAL  ANESTHESIA 


From  1908  to  1911  there  were  157  thyroidectomies  performed  under  local  anes-  j 
thesia  in  the  Hospital  at  Zwickau.  In  one  case  of  substernal  goitre,  local  anesthesia  ] 
was  found  most  serviceable.  The  upper  part  of  the  tumor  in  the  supraclavicular  1 
space  Avas  freely  exposed,  the  patient  was  then  told  to  cough,  and  after  a  very  few  j 
efforts  at  coughing,  a  little  traction  on  the  part  of  the  operator,  and  the  breaking-] 
up  of  a  few  adhesions,  he  literally  coughed  up  from  the  thoracic  cavity  a  goitre.^ 
weighing  390  grams.  There  can  be  no  doubt  at  the  present  time  that  local  ^ 
anesthesia  is  most  satisfactory,  both  for  removing  the  ordinary  goitre  and  for  theJ 
Basedow  operations.  * 


Fig.   110. — Method  of  injection  for  tracheotomy.     (Most.) 


Tracheotomy. — In  performing  tracheotomy,  two  entrance  punctures  should  bee 
made  to  the  right  and  left  of  the  trachea,  and  from  these  points  the  field  of  operation  i 
is  injected  in  a  trough-like  manner,  according  to  Fig.  31  (page  191).  A  diagram! 
illustrating  this  injection,  drawn  by  INIost,  is  shown  in  Fig.  110.  It  is  veryji, 
important  to  avoid  general  anesthesia  in  patients  suffering  from  stenosis  of  the^ 
trachea,  for  which  reason  it  is  advisable  to  use  local  anesthesia.  Young  children,  ij 
however,  are  often  so  restless  that  it  is  impossible  to  get  on  without  some  general  | 
anesthesia.  In  emergency  cases,  it  is  well  simply  to  infiltrate  along  the  line  oft 
incision. 


I 


OPERATIONS  OX   THE  NECK  275 


OPERATIONS  IN  THE  LARYNX. 


llepoatod  rot'erciice  lias  been  made  to  the  inestimable  ])enefit  to  the  field  of  laryn- 
gology by  the  introduction  of  cocain.  The  mucous  meml)rane  of  the  larynx  is  usually 
anesthetized  by  swabbing  it  with  a  10  to  20  per  cent,  cocain  solution  and  in  doing  this 
it  is  well  to  prevent  the  excess  of  the  cocain  solution  from  running  into  the  trachea 
and  esophagus.  After  the  swabbing,  the  patient  should  be  permitted  to  cough  and 
expectorate.  The  cocainizing  should  be  done  repeatedly,  in  order  to  arrest  the  reflexes 
of  the  mucous  membrane  of  the  larynx  long  enough  for  the  patient  to  bear  the 
introduction  of  the  instruments.  This  is  more  important  than  overcoming  the  sen- 
sation of  pain  which  is  evidently  very  slight  in  this  organ.  The  swabbing  is  very 
disagreeable  to  the  patient,  therefore  many  laryngologists  prefer  to  apply  a  small 
quantity  of  the  cocain  solution  to  the  larynx  wath  a  small  spraying  apparatus 
made  for  the  purpose,  or  with  a  syringe.  M.  Schmidt  prefers  the  syringe 
because  with  it  the  dosage  of  cocain  can  be  more  accurately  controlled.  The  effect 
of  the  cocain  lasts  from  5  to  10  minutes  and  much  longer  if  suprarenin  is  added. 
Siefert  and  Ruprecht  report  that  alypin  used  in  10  per  cent,  solution  with  the  addition 
of  suprarenin  is  a  splendid  substitute  for  cocain. 

The  sensory  innervation  of  the  larynx,  at  any  rate  that  part  above  the  vocal  cords, 
comes  through  the  internal  branch  of  the  superior  laryngeal  nerve.  This  ner^'e 
emerges  immediately  under  the  posterior  end  of  the  hyoid  bone,  then  runs  forward 
under  the  anterior  border  of  this  bone  for  a  short  distance  on  the  thyrohyoid  mem- 
brane which  it  penetrates,  sending  branches  into  the  mucous  membrane  of  the  larynx, 
the  pyriform  sinus,  and  the  surrounding  mucous  membrane  of  the  pharynx.  The 
other  two  nerves  which  enter  the  larynx  are  essentially  motor  nerves;  they  are  the 
external  branches  of  the  superior  laryngeal  and  of  the  recurrent  laryngeal. 

Eft'orts  to  anesthetize  the  larynx  by  a  bilateral  blocking  of  the  internal  branch  of 
the  laryngeal  nerve  were  unsuccessful  until  the  introduction  of  suprarenin. 

As  early  as  1903  the  author  succeeded  in  obtaining  such  complete  anesthesia 
that  Mereck,  a  surgeon,  was  able  to  curette  a  tuberculous  larynx.  Viereck,  who  con- 
tinued these  experiments,  asserts  that  the  anesthesia  always  extends  to  the  epiglottis 
and  the  entire  upper  part  of  the  cavity  of  the  larynx  to  the  glottis,  but  that  it  is 
not  always  complete  below  the  glottis.  Other  favorable  reports  have  been  made 
by  Frey,  Chevrier  and  Cauzard,  and  Kuttner.  It  is  a  very  simple  matter  to  accom- 
plish this  blocking.  A  needle  of  medium  size  is  inserted  under  the  skin  in  the  median 
line,  between  the  thyroid  cartilage  and  the  hyoid  bone,  then  into  the  thyrohyoid 
ligament.  It  is  directed  in  this  ligament  toward  the  end  of  the  hyoid  bone  which 
has  been  previously  located  by  the  examining  finger.     The  ligament  is  infiltrated 


276 


LOCAL  ANESTHESIA 


on  both  sides  with  5  c.c.  of  0.5  or  1  per  cent,  novocain-suprarenin  solution.  The  \ 
mucous  membrane  of  the  larynx  immediately  becomes  anemic  in  consequence  of  the  ' 
contraction  of  the  superior  laryngeal  artery,  produced  by  the  suprarenin.  ; 

Laryngotomy  and  Laryngectomy. — Fig.  Ill  illustrates  the  technique  of  injection  ^ 
necessary  for  this  operation.  Point  1  lies  under  the  lower  end  of  the  contemplated  i 
skin  incision  or  under  an  already  existing  tracheotomy  wound,  points  2  and  6  * 
are  close  beside  the  larynx,  points  3  and  5  are  on  each  side  of  the  lateral  ends 
of  the  hyoid  bone,  point  4  is  in  the  median  line  under  the  chin.  The  injection  J 
of    5   c.c.  of    a  0.5    per    cent,  novocain-suprarenin    solution    is    first    made    from  i 


6'.!  *2 


Fig.   111. — Laryngotomy  and  laryngectomy. 


point  4,  or  from  another  median  point  of  injection  into  both  sides  of  the  thyrohyoid 
ligament.  This  is  followed  by  deep  injections  of  0.5  per  cent,  novocain-suprarenin 
solution  from  points,  1,  2,  3,  5,  6,  which  include  the  larynx  and  trachea  in  a  cup-  ; 
shaped  manner,  according  to  Fig.  111.  Finally,  a  subcutaneous  circuminjection  is  j 
made  from  one  point  of  injection  to  another.  Altogether  about  100  c.c.  of  0.5  per  I 
cent,  novocain-suprarenin  solution  are  necessary.  Thanks  to  local  anesthesia,  opera-  I 
tions  on  the  larynx,  resections  of  the  jaw,  and  tongue  operations  have  assumed  a  j 
different  aspect  and  ha^-e  lost  all  of  their  technical  difficulty,  due  to  a  great  extent  j 
to  the  anemia  produced  by  the  suprarenin. 


OPEh'ATIOXS  OX   THE  XKCK  277 

When  the  extent  of  the  field  of  operation  is  indefinite,  as  when  a  eareinoiiia  lias 
penetrated  the  larynx,  requiring  the  removal  of  the  lymphatic  glands,  injections  in 
the  neighborhood  of  the  hirynx  cannot  be  considered.  In  such  cases  the  whole  front 
surface  of  the  neck  must  be  anesthetized,  according  to  Fig.  102,  and  the  thyrohyoid 
ligament  nuist  also  be  infiltrated. 

Subhyoid  Pharyngotomy. — A  subhyoid  pharyngotomy  for  the  removal  of  u  carci- 
noma at  the  entrance  of  the  larynx  and  surrounding  parts  has  been  performed  under 
local  anesthesia.  The  thyrohyoid  membrane  was  infiltrated  w'ith  0.5  per  cent. 
no\-ocain-suprarenin  solution.  The  field  of  operation  was  circuminjected  from  two 
l)oints  with  the  same  solution  in  the  shape  of  a  transversely  placed  rhombus  situated 
on  the  anterior  border  of  the  sternocleidomastoid  muscle.  After  opening  the  pharynx 
the  tumor  was  further  circuminjected. 


CHAPTER  XIII. 
OPERATIONS  OX  THE  SPINAL  COLUMN  AND  THORAX. 

The  Innervation. — Shortly  after  the  thoracic  nerves  emerge  from  the  intervertebral 
foramina  of  the  dorsal  vertebrae  they  send  out  connecting  branches  (rami  communi- 
cantes)  to  the  symphathetic  nerves,  and  then  divide  into  anterior  and  posterior 
branches.  The  latter  supply  the  muscles  of  the  back  and  innervate  the  skin  to  the 
right  and  left  of  the  median  line.  The  anterior  branches,  namely,  the  intercostal 
nerves,  at  their  origin  run  approximately  in  the  middle  of  the  intercostal  spaces. 
Near  the  angle  of  the  ribs,  they  approach  the  lower  border  of  the  rib  above.  At 
jfirst,  they  lie  immediately  upon  the  endothoracic  fascia  and  the  pleura;  as  they 
approach  the  angle  of  the  ribs  they  lie  between  the  external  and  internal  intercostal 
muscles.  Their  further  course  is  shown  in  Figs.  112  and  114.  The  lumbar  nerves 
lie  between  the  transverse  processes  of  the  lumbar  vertebrse,  in  front  of  the  transver- 
salis  muscle  connecting  the  transverse  processes,  and  are  surrounded  by  the  origin 
of  the  psoas  muscle.  The  iliohypogastric  and  ilio-inguinal  nerves,  which  are  the  most 
important  nerves  supplying  the  anterior  abdominal  wall,  are  derived  from  the  twelfth 
dorsal  and  first  lumbar,  running  like  the  twelfth  intercostal  nerve,  on  the  front  surface 
of  the  quadratus  lumborum  muscle,  then  between  this  and  the  outer  surface  of  the 
fatty  capsule  of  the  kidney,  continuing  between  the  transverse  and  oblique  abdominal 
muscles. 

From  the  second  lumbar  nerve,  the  emerging  nerve  trunks  take  such  a  decidedly 
downward  course  and  lie  so  close  to  the  vertebral  bodies  that  they  can  only  be  reached 
by  making  the  injection  close  to  the  vertebral  bodies. 

The  intercostal  nerves  and  the  first  lumbar  nerve  furnish  the  sensory  nerxe  supply 
to  the  chest  wall  and  abdominal  wall,  including  the  parietal  pleura  and  peritoneum. 

The  middle  intercostal  nerves  do  not  in  the  beginning  anastomose  with  one  another; 
the  first  and  second  intercostal  nerves  send  branches  to  the  brachial  plexus,  immedi- 
ately upon  their  emergence  from  the  foramina;  the  twelfth  intercostal  sends  branches 
to  the  first  lumbar  nerve.  The  intercostal  nerves  supplying  the  skin  overlap  each 
other  to  such  an  extent  that,  as  a  rule,  the  central  blocking  of  a  single  one  of  them  does 
not  perceptibly  alter  the  sensibility  of  the  skin.  The  overlapping  seems  to  occur 
to  a  greater  extent  from  the  upper  to  the  lower  segments,  so  that  by  the  central  block- 
ing of  a  number  of  intercostal  nerves,  anesthesia  of  the  skin  will  begin  two  segments 
lower  than  the  uppermost  injection. 


OPERATIONS  OX   THE  SPINAL  COLUMN  AND  THORAX 


279 


At  the  upper  end  of  the  bony  thorax,  in  the  infrachivicuhir  spaee,  at  the  ui)per 
border  of  the  seapuhi  and  in  the  axilhi,  the  sensory  innervation  is  supplied  by  the 
terminal  branches  of  the  cervical  and  brachial  plexus.  The  supraclavicular  nerves 
lie  subcutaneous,  crossing  the  clavicle  and  the  scai)ular  ridge  and  innervate  the  skin 
anteriorly  frequently  as  far  down  as  the  nipple. 


Ramus  posterior 


Ramus  anterior 


Fig.   112.— Diat:rai 


Sternum 

■l  the  course  of  the  intercostal  nerves.     (After  Corning.) 


Paravertebral  Conduction  Anesthesia. — In  this  connection  we  will  briefly  discuss 
the  experiment  already  mentioned  on  page  268,  viz.:  to  emphasize  the  possibility 
of  conduction  anesthesia  by  means  of  injections  into  the  inter\-ertebral  foramina. 
This  idea  originated  with  Sellheim,  who  attempted  to  block  the  eighth  to  twelfth 
intercostal  nerves,  as  well  as  the  iliohypogastric  and  ilio-inguinal  nerves  at  their  emer- 
gence from  the  spinal  column  for  abdominal  operations,  and  gave  explicit  directions 
for  introducing  and  passing  the  needle.  According  to  his  suggestion,  the  needle  is 
inserted  laterally  2  to  3  cm.  from  the  median  line  until  the  vertebral  arch  is  touched. 
It  is  then  passed  laterally  over  the  border  of  the  vertebral  arch  between  two  trans- 
verse processes,  for  1  to  2  cm.  more;  on  the  posterior  surface  of  the  vertebral 
arch  it  encounters  the  ner\es  emerging  from  the  spinal  foramen.  While  Sellheim's 
experiments  were  not  altogether  a  failure,  they  were  nevertheless  jiractically  impossible 
on  account  of  the  inefficient  means  of  anesthesia  then  in  use. 


280 


LOCAL  ANESTHESIA 


Fig.   113. — Intercostal  and  sympathetic  nerves.     (After  Spalteholz.) 


01-Ell.vn„xs  „x  THE  SI'ISM  rnUM.x  .l.v/;  rWiUAX 


Fig.    114.— rour.cof  111.   nitPHostdmn,.      (  Aftc .  sp  dti  Iml/  ,      11, 
oblKjiH  inu^dfs  hui    iMdi  i(iii()\(fl 


282  LOCAL  ANESTHESIA  1 

Laewen  was  more  successful  in  his  efforts.  He  called  the  method  "paravertebral 
conduction  anesthesia."  In  191 1  he  reported  having  performed  operations  for  inguinal 
hernia  and  nephrotomy  (see  Chapter  XV)  after  blocking  the  lower  dorsal  and  lumbar 
nerves.  Finsterer  used  this  method  in  major  operations  in  the  lower  abdomen 
(Chapter  XIV).  Laew^en  anesthetized  the  twelfth  intercostal  nerve  and  the  first  to 
third  or  fourth  lumbar  nerves.  He  inserted  the  needle  laterally  4  cm.  from  the  upper- 
most angle  of  the  spinous  processes,  between  the  transverse  processes,  directed  it 
slightly  inward  and  injected  10  c.c.  of  a  1  per  cent,  novocain-bicarbonate  solution. 
Finsterer  injected  the  eleventh  to  twelfth  dorsal  and  the  first  to  third  lumbar  nerves, 
the  point  of  entrance  being  3  to  3.5  cm.  outward  from  the  median  line.  The  needle 
is  directed  over  the  upper  edge  of  the  transverse  processes  and  inserted  1  to  1.5  cm. 
beyond;  5  c.c.  of  a  1  per  cent,  novocain-suprarenin  solution  is  then  injected  in  a 
fan-shaped  manner. 

It  has  been  proved  (Kappis,  Franke)  that  the  injection  is  dangerous  if  made  directly 
at  the  intervertebral  foramen,  as  the  solution  may  penetrate  the  dura  and  reach  the  ' 
spinal  canal,  or  the  dura  may  be  punctured  and  injection  made  directly  into  the  spinal 
canal.  These  accidents  have  resulted  in  serious  collapse,  for  which  reason  it  is  neces- 
sary to  try  to  reach  the  nerves  a  short  distance  from  their  point  of  emergence  by 
guiding  the  needle  according  to  the  suggestions  of  Laewen  and  Finsterer. 

Kappis  made  comprehensive  efforts  with  these  methods  in  the  clinics  at  Kiel. 
His  method  of  injecting  the  anesthetic  in  front  of  and  close  to  the  transverse 
processes  of  the  cervical  vertebra  is  mentioned  on  page  268.  The  injection  method 
for  the  first  to  the  twelfth  dorsal  nerves,  and  the  first  to  the  fourth  lumbar  nerves, 
is  described  by  Kappis  as  follows: 

The  point  of  injection  lies  3.5  cm.  from  the  median  line.  At  a  depth  of  4  to  5  cm. 
the  rib,  or  the  transverse  process,  is  felt,  and  the  point  of  the  needle  is  then 
directed  past  the  lower  border  of  this  bone.  When  this  has  been  done,  the  needle 
is  directed  toward  the  median  line  at  an  angle  of  20°  to  30°  and  is  pushed  from  1 
to  1.5  cm.  deeper  and  in  this  direction  5  c.c.  of  1.5  per  cent,  novocain-suprarenin 
solution  are  injected.  Besides  operations  on  the  thorax  this  method  is  suitable  for 
kidney  operations  which,  according  to  Kappis,  were  frequently  done  by  injecting 
unilaterally  the  eighth  dorsal  to  the  first  lumbar.  After  a  bilateral  blocking  of  the 
fifth  to  twelfth  dorsal  and  first  to  third  lumbar,  for  which  22  points  of  entrance  and 
110  c.c.  of  a  1  per  cent,  novocain-suprarenin  solution  were  necessary,  a  number  of 
painless  laparotomies  and  bile-duct  operations  were  performed.  This  method  will 
be  referred  to  again  in  the  description  of  abdominal  and  kidney  operations. 


OPERATIOXS  OX   THE  SPINAL   COLUMN  AND    THORAX 


283 


OPERATIONS    ON    THE    SPINAL    COLUMN. 

The  use  of  local  anesthesia  is  of  special  value  in  i)erf()rniin<;-  laminectomies,  owing 
to  the  field  of  operation  being  rendered  bloodless  (Braun). 


Just  as  operations  in  the  region  of  the  trigeminus  assume  a  totally  different  char- 
acter after  injections  of  novocain-suprarenin  solution,  so  do  operations  on  the  spinal 
column.  They  can  be  performed  almost  without  any  bleeding,  and  the  patient  leaves 
the  operating  table  in  a  decidedly  better  condition  than  we  have  formerly  been  in 
the  habit  of  seeing.  The  unpleasant  necessity  of  operating  in  two  stages  is  not 
experienced  in  either  laminectomy  or  Foerster's  operation.  A  detailed  discussion  of 
these  operations  is  needless  at  this  time.     The  Foerster  operation  was  performed 


284  LOCAL  ANESTHESIA  W 

upon  one  side  of  a  corpulent  elderly  lady  with   spastic  spinal    paralysis  without    ' 
noticeably  affecting  her  general  condition.  ; 

In  laminectomies,  in    addition    to    local  anesthesia,   general    anesthesia   should 
always  be  used  in  certain  phases  of  the  operation,  as  the  Foerster  operation  is  hardly 
possible  without  it,  if  the  operator  wishes  to  avoid  intradural  injections.    Simple    ; 
laminectomy  for  the  relief  of  pressure  on  the  spinal  cord  can,  according  to  Heidenhain    • 
and  Krause,  be  frequently  performed  without  general  anesthesia. 

In  performing  laminectomy,  the  best  method  is  usually  as  follows  (Fig.  115):  ' 
A  number  of  points  of  entrance  are  marked  surrounding  the  field  of  operation.  This  " 
should  be  sufficiently  large  so  that  one  is  in  no  way  hampered.  The  next  step  is  to  j 
make  a  bilateral  injection  of  a  1  per  cent,  novocain-suprarenin  solution,  according  to  | 
Kappis,  between  the  ribs  and  transverse  processes  respectively.  Then  the  erector  ^ 
spinse  muscle  is  thoroughly  infiltrated  to  the  spinous  tranverse  processes  and  the  J 
ribs  w'ith  a  0.5  per  cent,  novocain-suprarenin  solution,  and  finally  the  whole  field  of  -] 
operation  is  subcutaneously  circuminjected  with  the  same  solution.  In  exposing  ; 
the  spinal  column  there  is  no  pain  in  any  case.  If  the  patient  complains  during  the  ! 
removal  of  the  bony  parts,  it  is  advisable  to  give  a  little  ether.  There  is  practically  i 
no  bleeding.  | 

OPERATIONS   ON   THE   THORAX. 

Puncture  of  the  Pleura. — Anesthesia  for  pleural  puncture  is  produced  (according  to 
Fig.  28  (page  188)  with  a  very  fine  needle.  For  this  injection  0.5  per  cent,  novocain- 
suprarenin  solution  is  sufficient.  It  is  much  easier  on  the  patient  if  the  anesthesia 
instead  of  being  limited  to  freezing  the  skin  extends  over  the  entire  tract  to  the 
pleura  before  inserting  a  thick  needle  or  trocar. 

Resection  of  Ribs  and  Thoracotomy  for  Empyema. — Fig.  116  represents  three 
successive  ribs;  from  the  middle  one  that  part  is  to  be  resected  which  is  marked  in 
black.  Wheals  marking  the  four  points  for  injection  are  made  over  the  two  neigh- 
boring intercostal  spaces,  and  at  these  points  the  needle  is  inserted  perpendicularly 
to  the  surface  of  the  skin,  and  5  c.c.  of  1  per  cent,  novocain-suprarenin  solution  is 
injected  between  and  into  the  intercostal  muscles.  In  making  this  injection,  the  point 
of  the  needle  should  always  seek  the  next  rib  above  in  order  to  find  the  necessary 
depth,  and  then  pass  along  its  lower  border  into  the  intercostal  space.  The  muscle 
covering  the  rib  and  the  subcutaneous  connective  tissue  are  then  infiltrated  with 
30  to  40  c.c.  of  a  0.5  per  cent  novocain-suprarenin  solution  in  the  direction  of  the 
arrows.  This  operation  is  always  performed  under  local  anesthesia,  even  in  children 
under  four  years  of  age,  the  patient  being  placed  in  a  sitting  posture.  In  children 
it  is  usually  necessary  to  use  some  pyschic  influence;  if  they  permit  the  injection  to 


OPERATIOXS  OX   THE  SPINAL  COLCMX   A XI)   THORAX  2Sr) 

!)(•  made,  however,  the  rest  is  easy.     Oiu-  of  our  httle  i)atieiits  ate  a  sandwich  (hiring 
the  operation.     Fiii'.  1 17  represents  a  patient  <hn'in^-  the  resection  of  a  rih. 


Fig.  116. — Injection  for  resection  of  the  ribs  for  empyema.     (Diagrammatic.) 


Fig.   117. — Patient  during  resect 


for  eiiipyenia.     Skin  is  painted  with  iodine. 


Resection  of  Several  Ribs  or  Rib  Cartilages  and  Parts  of  the  Thoracic  Wall. — If 

the  described  intercostal  injeetions  are  made  not  only  in  one,  hut  in  two,  three,  or  four 
intercostal  spaces,  in  front  of  and  behind  the  field  of  operation,  and  if  the  soft  parts 
covering  the  thorax  are  eireuminjected  with  a  0.5  novocain-suprarenin  solution 
(Fig.  118),  larger  areas  of  the  thoracic  wall  can  b(^  made  insensible;  large  pieces 
of  rib  can  be  removed  and  parts  of  the  thoracic  wall  can  be  resected. 


286 


LOCAL  ANESTHESIA 


Fig.   118. — Anesthesia  of  several  ribs  by  intercostal  injections  and  circuminjection, 


Fig.   119.— Injection  for 


1  and  fifth  rib  cartilages 


OPEBATIOXS  OX   THE  SPINAL   COLUMN   AND   TUONAN 


2S7 


Resection  of  Cartilage  of  Second  to  the  Fifth  Ribs  in  the  Fixed  Dilated  Thorax. — 
Over  the  second  to  fifth  intercostal  spaces  mark  two  rows,  eacli  ha\ii)^  five  points 
of  injection  (Fig.  110).  Of  these  the  lateral  row  lies  beyond  the  border  of  the  car- 
tilage of  the  ribs;  the  median  row  lies  close  to  the  sternum.  From  each  of  these 
points  inject  in  the  usual  manner,  5  c.c.  of  a  1  per  cent,  novocain-suprarenin  solution 
into  the  intercostal  spaces;  the  field  of  operation  is  circuminjected  in  the  direction 


Fig.  120. — Patient  after  resection  of  second  and  fifth  rib  cartilages  with  the  intercostal  muscles  for 
emphysema,  under  local  anesthesia.  The  field  of  operation  is  covered  with  oiled  silk.  The  base  of  the 
wound  is  formed  by  the  pleura. 


of  the  dotted  line  with  50  c.c.  of  a  0.5  per  cent,  novocain-suprarenin  solution.  The 
operation  is  painless  and  bloodless.  Fig.  120  shows  one  of  the  patients  during  the 
operation.  The  rib  cartilage  is  removed  together  with  the  intercostal  muscles, 
according  to  Krueger.  The  base  of  the  wound  forms  the  pleura.  On  account  of 
the  deep  respiratory  movements  the  photogram  is  not  clear;  at  any  rate  it  will 
show  what  can  be  done  with  local  anesthesia. 

The  same  method  of  anesthesia  is  suitable  in  operations  on  the  heart  and  pericar- 
dium. The  author  had  only  one  opportunity  to  use  it  in  pericardiotomy,  and  that 
for  purulent  pericarditis  in  a  child. 


288 


LOCAL  ANESTHESIA 


He  has  for  years  operated  for  subphrenic  abscesses  which  were  to  be  opened  through 
the  thorax,  a  few  lung  abscesses,  a  few  cases  of  circumscribed  rib  tuberculosis, 
and  thoracoplasty'  for  small  localized  empyemas.  The  latter  were  not  always 
satisfactory,  for  in  old  empyemas,  as  Schumacher  has  pointed  out,  the  ribs  are  so 
crowded  together  and  overlap  one  another  to  such  an  extent  that  the  intercostal 
injections  in  the  neighborhood  of  the  field  of  operations  are  fraught  with  numerous 
difficulties.  These  difficulties  do  not  arise  when  the  injections  are  made  close  to  the 
spinal  column. 

Operations  on  the  Sternum. — The  injection  is  made  as  far  as  it  is  necessary  on 
both  sides  into  the  intercostal  spaces,  close  to  the  sternum,  with  5  c.c.  of  1  per  cent, 
novocain-suprarenin  solution;  the  field  of  operation  is  then  subcutaneously  circum- 
injected  with  a  0.5  per  cent,  solution. 


Fig.   121. — Subcutaneous  line  of  inject 


lie  first  to  twelfth  intercostal  i 


The  Central  Blocking  of  the  Intercostal  Nerve. — Schumacher  and  Kappis  have  i 
reported  performing  thoracoplasty  with  simple  conduction  anesthesia.  Schumacher  j 
states  that  in  35   cases    (resection  of  pieces  of  fourth  to  the  eighth  ribs)  he  had  I 


Ol'ERATIOXS   OX    THE  SI'IXAL   COIAMX   AXD   THORAX 


289 


complotc  aiu'stlu'sia  in  20  cases,  and  in  1 ")  cases  a  liulit  u'cncral  anesthetic  was  necessary. 
Kappis  was  able  to  remove  the  ninth  and  tenth  ribs  entirely,  and  the  fi;reater  portion 
of  the  fifth  to  the  eighth  and  the  eleventh  by  means  of  a  simple  conduction  anesthesia, 
induced  by  blocking  the  spinal  nerves  from  the  fourth  to  the  eleventh  dorsal  vertebrie. 
In  thoracoplasty  (fourth  to  the  sixth  ribs)  Hirschel  injected  not  only  into  the  back 
i)ut  also  anteriorly  into  the  intercostal  spaces  besides  circuminjecting  the  area  for 
the  formation  of  Schede's  flap.    He  seems  to  have  used  the  method  as  described  by  the 


\¥ 


—Blocking  of  first  to  tenth  intercostal  nerves  for  breast  amputation.     The  upper  needle  is 
in  the  first  intercostal  space,  the  lower  needle  locates  the  second  rib. 


writer.  It  is  not  necessary  in  operations  on  the  thorax  to  block  close  to  the  spinal 
column,  in  fact  it  is  better  to  block  along  the  lateral  border  of  the  erector  spinse,  near 
the  angle  of  the  rib  (Schumacher  and  Franke),  which  is  about  5  cm.  distant  from  the 
spinal  line.  Even  in  the  shrunken  thorax  the  intercostal  spaces  are  easily  accessible. 
The  technique  of  the  injection  is  as  follows:  It  is  assumed  that  all  the  nerves,  or 
perhaps  the  intercostal  nerves,  are  to  be  blocketl.  It  is  advisable,  on  account  of  the 
many  points  of  injection,  the  position  of  which  cannot  previously  be  definitely 
determined,  to  deviate  from  the  usual  rule  of  marking  them  by  means  of  wheals  and 
19 


290  LOCAL  ANESTHESIA 

follow  Schumacher's  plan.  He  infiltrates  siibciitaneoiisly  the  entire  strip  in  which  ■ 
the  points  of  entrance  are  to  lie  with  long  needles  from  a  few  points  with  a  0.5  j 
per  cent,  novocain-suprarenin  solution  (Fig.  121).  The  patient  sits,  leaning  forward  J 
with  shoulders  drawn  forward.  A  needle  is  inserted  into  the  infiltrated  strip,  about  ^ 
on  a  level  with  the  spinous  process  of  the  first  dorsal  vertebra  and  with  its  point  the  i 
first  rib  is  located.  This  is  very  easy  in  lean  persons,  but  in  fat  or  muscular  subjects,  \ 
some  little  time  is  required  to  find  it.  As  soon  as  the  rib  is  located,  the  operator  feels  ; 
his  way  along  the  under  border  and  when  the  resistance  of  the  bone  is  passed,  the  1 
needle  is  pushed  about  0.5  cm.  deeper,  and  5  c.c.  of  a  1  per  cent,  solution  of  novocain-  i 
suprarenin  is  injected.  In  order  to  find  the  location  more  surely  leave  the  needle  in  ., 
position,  place  a  second  needle  underneath  the  first,  locate  the  second  rib  in  the  same  i 
manner  and  likewise  inject  the  second  intercostal  space  (Fig.  122).  Then  remove  the 
first  needle  and  place  it  on  the  third  rib  and  make  the  injection  into  the  third  intercostal  • 
space,  etc.  If  the  upper  ribs  are  not  to  be  injected  it  is  advisable  to  begin  with  one  , 
of  the  lower  ribs  which  is  more  easily  palpated.  This  is  a  very  simple  and  reliable  I 
procedure,  and  is  quickly  performed.  With  a  little  precaution  the  puncturing  of  I 
the  pleura  can  be  avoided,  especially  if  care  is  taken  not  to  insert  the  needle  until  ) 
the  rib  above  has  been  felt.  J 

After  this  injection  is  made,  it  is  necessary  to  wait  a  little  longer  for  the  anesthesia   ] 
to  become  fully  effective  than  after  the  intercostal  injections  near  the  field  of  operation    : 
(about  fifteen  minutes).     The  intercostal  spaces,  the  ribs,  and  the  pleura,  in  the 
locality  which  has  been  injected,  ^dll  be  found  insensitive  as  far  forward  as  the  > 
sternum.   For  this  reason  it  will  not  be  necessary  to  make  further  intercostal  injections 
in  front.      The  limit  of  skin  anesthesia  is  reached  approximately  in  the  area  of    i 
distribution  of  the  lowest  intercostal  nerve,  which  has  been  blocked,  while  the  upper 
limit,  as  already  shown  on  page  289,  lies  one  or  two  ribs  lower,  irrespective  of  the    I 
overlapping  of  the  cervical  plexus.     In  front  the  skin  anesthesia  reaches  almost  to    ! 
the  median  line.    On  the  back  it  usually  ceases  where  the  points  of  injection  lie,  but   j 
very  often  the  lateral  injections  also  block  the  posterior  branches  of  the  thoracic  j 
nerves,  in  which  case  the  skin  anesthesia  will  reach  almost  to  the  spinal  processes 
in  the  back.    This  statement  can  be  explained  by  considering  two  cases  in  which  it 
was  possible  to  determine  definitely  the  extent  of  skin  anesthesia. 

In  one  case  of  subphrenic  abscess  after  appendicitis  a  5  c.c.  of  1  per  cent,  novocain- 
suprarenin  solution  was  injected  into  each  intercostal  nerve,  from  the  eighth  to  the 
twelfth  respectively  (Figs.  123  and  124,  right  side  of  body).  The  line  shows  the  area 
of  anesthetized  skin,  the  posterior  branches  of  the  thoracic  ne^^•es  also  being  blocked. 
The  upper  limit  of  anesthetized  skin  terminates  abrui^tly  at  the  tenth  rib.  As  pieces 
of  the  tenth  and  eleventh  ribs  were  to  be  resected  in  the  posterior  axillary  line,  it 
was  necessary  to  widen  the  area  of  skin  anesthesia  for  the  incision  by  means  of 


OPERATIONS  ON   THE  SPINAL  COLUMN  AND   THOh'AN  291 


Fig.   123. — Extent  of  conduction  anesthesia  after  intercostal  injectic 


Fig.    124.— Extent  of  conduction  anesthesia  after  intereo^tal  injections. 


292 


LOCAL  ANESTHESIA 


subcutaneous  injections.  After  that  the  operation  was  absohitely  painless,  as  was 
also  the  splitting  of  the  diaphragm  and  peritoneum  and  the  exploring  and  draining 
of  the  large  abscess. 

In  the  second  case  it  was  necessary  to  make  an  incision  into  the  seventh  inter- 
costal space,  in  order  to  remove  a  piece  of  scissors  which  had  penetrated  the  cavity, 
resulting  in  pneumothorax.  Into  each  nerve  from  5.  to  9.  intercostal,  5  c.c.  of  a  1 
per  cent,  novocain-suprarenin  solution  was  injected  (Figs.  123  and  124,  left  side  of 
body).  The  line  drawn  indicates  the  extent  of  skin  anesthesia.  The  operation  was 
painless,  without  further  injections.  Since  the  intercostal  arteries  contract,  follow- 
ing these  injections,  as  a  result  of  the  action  of  the  suprarenin,  the  blood-supply  to  the 
field  of  operation  is  lessened. 


— Suliciitaneous  line  of  injection  for  blocking  the  supracl; 


In  complicated  extensive  operations  on  the  lower  thoracic  wall,  downward  from 
about  the  fifth  intercostal  space,  absolute  anesthesia  of  both  the  anterior  and  posterior 
thoracic  walls  can  be  obtained,  almost  to  the  median  line,  by  a  central  blocking  of  a 
sufficient  number  of  intercostal  nerves  with  a  moderately  small  amount  of  the  anes- 
thetic— 60  c.c.  of  a  1  per  cent,  novocain-suprarenin  solution  for  all  of  the  twehe 
intercostal  nerves.    No  other  injections  or  circuminjections  are  necessary. 

For  operations  on  the  upper  part  of  the  bony  thorax,  central  blocking  is  not  suffi- 
cient on  account  of  the  overlapping  of  the  sensory  innervation  from  the  neck. 


OPEh'ATlOXS   OX    Till-:   SI'IXAL    COIAMX    AXI)    'IIIOh'AX 


293 


The  supraclavirular  luTves  are  especially  easily  blocked  Ity  suhcutaneous  injections 
of  0.5  per  cent,  novocain-suprarenin  solution  made  in  a  stri])  which  follows  the  clavicle 
and  if  necessary  may  run  for  a  short  distance  on  the  spine  of  the  scapula  (Fig.  125). 
If  the  field  of  operation  extends  into  the  axilla,  or  supraclavicular  space,  then  the  bra- 
chial plexus  must  be  blocked  (see  Chapter  XVI).  In  order  to  exclude  the  nerve  anas- 
tomoses from  behind  the  cervical  plexus;  Franke  recommends  infiltration  along  the 
posterior  border  of  the  trapezius  muscle.  It  is  possible  to  anesthetize  the  entire  half 
of  the  thorax  and  at  the  same  time  the  entire  arm  with  a  moderate  quantity  of  the 
anesthetic.  p]\ery  indication  points  to  the  fact  that  the  time  is  not  far  distant  when 
almost  the  whole  field  of  thoracic  surgery  will  come  under  the  head  of  local  anesthesia. 
This  will  greatly  simplify  operations  under  differential  pressure. 


OPERATIONS    ON    THE    BREAST. 

It  is  a  very  easy  matter  to  remove  from  the  breast  a  well  defined  benign  tumor, 
whether  large  or  small,  under  local  anesthesia.  Two  or  four  points  of  entrance  are 
marked  in  the  neighborhood  of  the  field  of  operation,  the  tumor  is  lifted  up  from 


12f). — f'ircuniinjection  of  a  fibroma  of  the  breast. 


the  underlying  structure  (Fig.  12())  with  the  left  hand,  and  a  pyramidal  circumin- 
jection  of  50  to  75  c.c.  of  a  0.5  per  cent,  novocain-suprarenin  solution  is  made.  In 
lean  women  with    small  breasts  the  injection  beneath  and  around  the  gland  from 


294  LOCAL  ANESTHESIA 

several  points  will  sometimes  be  sufficient  for  ablation  of  the  breast.  InJflammatory 
and  especially  phlegmonous  conditions  are  better  operated  under  ethyl  chlorid  or 
ether  anesthesia. 

Excision  of  a  Cancerous  Breast. — Occasional  operations  of  this  kind  were  formerly 
done  under  local  anesthesia  by  Schleich,  more  recently  by  Chaput,  Hirschel, 
Hohmeier  and  Eberle.  Hirschel  operated  on  3  cases  in  lean  women.  They  were 
not  classical  operations,  as  only  small  parts  of  the  chest  muscle  were  removed. 
Hohmeier  also  limited  the  use  of  local  anesthesia  to  appropriate  cases  in  lean  women 
with  small  movable  tumors. 

Eberle  has  operated  on  6  cases,  some  of  them  fat  women.  The  most  thorough 
injection  was  made  beneath  and  around  the  mamma  and  the  chest  muscle,  together 
with  intercostal  injections  in  the  lateral  and  front  wall  of  the  thorax,  with  infiltra- 
tion of  the  boundaries  of  the  axilla  and  injections  into  the  nerve  bundles  in  the 
axilla.  In  this  manner  the  author  has  for  years  attempted  to  carry  out  the  classical 
breast  amputations  in  lean  patients;  the  anesthesia  was  satisfactory  in  most  cases, 
but  it  is  improbable  that  this  method  of  local  anesthesia  can  ever  come  into  general 
use  for  amputations  of  the  breast. 

The  amount  of  anesthetic  necessary  is  great  (200  to  300  c.c.  of  0.5  per  cent, 
novocain-suprarenin  solution).  The  anesthesia  is  not  at  all  reliable,  the  technique 
of  the  injection  is  awkward,  and  injections  into  the  neighborhood  of  the  diseased 
breast  are  not  advisable  and  not  permissible  in  the  axilla  in  the  presence  of  a 
carcinoma. 

We  now  have  the  technique  which  had  to  be  devised  before  such  operations 
could  be  thought  of.  With  a  simple  reliable  conduction  anesthesia,  induced  with- 
out coming  into  contact  with  the  diseased  parts,  the  very  large  field  of  operation 
which  is  necessary  in  a  modern  operation  for  carcinoma  can  be  rendered  insensitive. 
For  this  operation  anesthesia  of  the  brachial  plexus  above  the  clavicle  (see  Chapter 
XVI)  outside  of  the  axilla  and  the  central  blocking  of  a  number  of  intercostal 
nerves  is  necessary. 

The  blocking  of  the  brachial  plexus  is  performed  according  to  the  method  of 
Kulenkampff  (10  c.c.  of  a  2  per  cent,  or  5  c.c.  of  4  per  cent,  novocain-suprarenin  solu- 
tion). This  is  followed  by  the  blocking  of  the  first  to  the  tenth  intercostal  nerves  as 
described  on  page  290;  (50  c.c.  1  per  cent,  novocain-suprarenin  solution),  and  finally 
75  to  100  c.c.  0.5  per  cent,  novocain-suprarenin  solution  are  injected  subcutaneously 
in  a  continuous  small  narrow  strip,  beginning  at  the  acromion  and  following  the 
clavicle  along  the  median  line,  or  alongside  of  it,  then  downward  in  a  curve  following 
the  lower  end  of  the  thorax  and  finally  continuing  backward  to  the  strip  indicated 
for  the  intercostal  injections  (Fig.  127).  This  subcutaneous  injection  includes  the 
supraclavicular  nerves  and  the  lower  overlapping  innervation  from  the  other  side. 


OPERATIONS  ON   THE  SPINAL  COLUMN  AND    THORAX 


295 


After  this  injection  has  been  carried  out,  which  will  take  about  fifteen  minutes,  an 
absolute  anesthesia  of  the  entire  field  of  operation  will  be  obtained  and  no  further 
injections  or  circuminjections  will  be  necessary.  Fat  persons  need  no  more  of  the 
anesthesia  than  lean  ones.  At  least  twelve  operations  for  carcinoma  of  the  breast 
have  been  operated  upon  successfully  in  this  way  and  the  method  will  be  found 
worthy  of  general  acceptance. 


OPERATIONS    IN    THE    AXILLA. 


Superficial  operations  in  the  axilla  are  performed  after  injections  under  and 
around  the  field  of  operation.  As  soon  as  the  operator  penetrates  deeper  into  the 
axilla  it  becomes  necessary  to  block  the  brachial  plexus  and  the  five  upper  inter- 
costal nerves,  in  order  to  obtain  a  complete  anesthesia  of  the  axilla. 


CHAPTER   XIV. 
ABDO.AIIXAL  OPERATIONS. 

The  possibility  of  performing  abdominal  operations  under  local  anesthesia  depends 
upon  a  number  of  circumstances,  which  must  be  considered  in  each  individual  case. 
It  is  a  fact  which  was  assured  after  the  introduction  of  the  ether  spray  that  anesthesia 
of  the  skin  incision  is  usually  all  that  is  necessary  for  opening  the  abdomen,  and  for 
operations  on  the  abdominal  organs  which  have  little  or  no  sensation  to  pain.  Bloch, 
who  evidently  had  splendid  material  to  work  upon,  has  recently  brought  further  proof 
that  this  is  often  the  case.  Local  anesthesia  with  cocain  and  its  substitutes  has 
made  wonderful  progress;  for  now,  even  in  sensitive  patients,  a  real  exclusion  of  sensa- 
tion is  possible,  permitting  the  abdominal  layers  to  be  incised  from  skin  to  peritoneum 
with  ease  and  comparative  safety. 

If  the  operation  is  to  be  performed  in  or  upon  the  abdominal  wall,  as  is  the  case 
in  most  operations  for  hernia,  or  if  a  simple  incision  through  the  abdominal  wall 
immediately  exposes  the  organ  to  be  operated  upon,  and  if  further  manipulation 
in  the  abdominal  cavity  is  not  necessary,  then  local  anesthesia  will  be  sufficient. 
Incisions  into  the  stomach  and  bowel,  the  liver  and  gall-bladder  and  other  abdomi- 
nal organs  are  not  painful.  The  sensibility  of  these  organs  is  the  same  whether  in  an 
inflammatory  or  non-inflammatory  state.  On  the  other  hand,  painful  sensations, 
called  "abdominal  sensations"  (page  38),  are  produced  by  any  traction  on  the  bowel, 
or  any  touch  or  tearing  of  the  parietal  peritoneum,  if  not  anesthetized.  Pains  are  also 
often  felt  in  tying  off  the  mesentery,  but  usually  not  in  tying  oflp  the  omentum.  The 
intensity  of  these  sensations  differs  in  each  individual.  In  some  patients  it  is 
possible,  after  incising  the  abdominal  wall,  to  perform  any  abdominal  operation 
desired  without  a  complaint,  Frequently,  however,  this  is  not  the  case.  Usuallj^ 
any  examination  of  the  abdominal  organs,  the  introduction  of  the  hand  into  the 
abdominal  cavity,  the  application  and  removal  of  compresses,  the  separation  of 
adhesions,  is  so  painful  that  further  operation  is  not  to  be  considered.  "\'arious 
efforts  have  been  made  to  overcome  these  abdominal  sensations.  On  page  38  is 
described  one  method,  namely,  by  paravertebral  conduction  anesthesia.  When  this 
this  has  been  successfully  brought  about,  then  not  onl}'  the  abdominal  wall  becomes 
insensitive  but  the  abdominal  muscles  relax  and  abdominal  sensations  are  absent. 
Kappis  declares  that  for  an  operation  in  the  up])er  abdominal  cavity  a  bilateral 


Al^DOMIXAL    (>ri-:/x'ATl(>.\S  2!)7 

l)l()ckin,u'  from  the  first  to  Xhv  third  himhar  iktvcs,  and  from  the  fiftli  to  the  twcH'th 
dorsal  nerves,  is  neeessary.  Kappis  was  able  in  this  way  to  perform  resections  of  the 
stomaeh,  gastro-enterostomies, gall-bhulder  operations  and  other  laparotomies  without 
pain.  This  is  of  great  interest  in  that  it  proves  that  the  vagus  has  absolutely  nothing 
to  do  with  the  sensory  innervation  of  these  parts.  These  injections,  however,  greatly 
tax  the  patience  of  the  surgeon  as  well  as  the  patient,  for  it  is  necessary  to  have  22  points 
of  injection,  and  into  each  of  these  at  least  5  c.c.  of  1  per  cent,  novocain-suprarenin 
solution  (Kappis  uses  1.5  per  cent.)  must  be  injected,  requiring  a  comparatively  large 
dose  of  the  novocain.  It  is  much  easier  to  perform  a  unilateral  paravertebral  blocking. 
Laewen  uses  it  for  hernia  operations  and  Finsterer  for  large  unilateral  abdominal 
operations,  also  operations  in  the  lower  abdomen.  They  succeeded  in  getting  complete 
anesthesia  in  this  way.  Kappis  declares  that  in  operations  on  the  appendix  the  aljdomi- 
nal  sensations  are  present,  a  fact  which  the  author  has  also  observed.  The  use  of 
this  method  is  still  in  the  experimental  stage.  Further  efforts  have  been  made  to 
get  rid  of  the  abdominal  sensations  by  making  secondary  injections,  after  the  ordinary 
anesthetizing  has  been  done,  for  example,  into  the  broad  ligament  (Schleich)  or  into 
the  mesenteriolium  (Hesse),  but  complete  success  cannot  be  expected  from  this 
method. 

The  results  obtained  by  the  combination  of  local  and  general  anesthesia  are  much 
more  satisfactory.  This  method  was  first  recommended  by  Schleich  for  abdominal 
operations,  later  practiced  by  von  ^Mikulicz  and  more  recently  by  Bakes  and  Laewen ; 
it  has  also  been  warmly  recommended  by  Finsterer. 

The  abdominal  layers  are  made  insensitive,  followed  by  light  general  anesthesia 
in  certain  phases  of  the  operation  in  which  the  abdominal  sensations  are  to  be 
expected.  This  procedure  will  be  much  more  effective  if  the  patient  is  previously 
prepared  by  the  administration  of  morphium,  pantopon  or  scopolamin.  In  the  latter 
case  general  anesthesia  can  be  omitted  altogether.  This  method  has  been  regularly 
used  in  abdominal  operations  on  individuals  who  are  greatly  emaciated,  for  example, 
in  stomach  operations. 

Reclus  and  Schleich  anesthetized  the  abdominal  layers  in  the  line  of  the  proposed 
incision.  Schleich  states  that  after  layer  infiltration  had  been  made,  and  after 
cutting  through  the  skin,  the  subcutaneous  connective  tissue,  aponeurosis,  muscles 
and  fascia,  a  special  infiltration  of  the  peritoneum  was  necessary.  This  he 
describes  in  the  following  manner:  "The  contents  of  half  a  sj'ringe  is  emptied 
into  the  deepest  layers  of  the  preperitoneal  fat,  which  has  been  lifted  up  by  hooks; 
the  peritoneum  is  painlessly  opened  at  this  point,  the  finger  is  inserted  and  pressure 
is  made  against  the  peritoneum  in  the  direction  of  the  proposed  incision,  in  order 
to  elevate  it,  and  then  guided  by  the  finger  the  needle  is  pushed  forward,  either 
sub-  or  intraperitoneally.    Then  by  making  pressure  upon  the  syringe  the  operator 


298  LOCAL  ANESTHESIA 

can  feel  the  peritoneum  swell,  and  the  peritoneal  wheal  raise  against  the  finger.  The 
spot  thus  distended  is  cut  through  and,  guided  by  the  finger,  further  infiltration 
is  made  and  the  peritoneum  is  cut  through,  step  by  step,  upward  or  downward, 
according  to  the  extent  desired.  At  the  same  time  it  must  be  remarked  in 
making  this  infiltration  that  if  the  peritoneum  is  inflamed,  solution  1  must  be  used 
(Schleich  solution  1,  i.  e.,  0.2  per  cent,  cocain  solution)." 

Reclus  did  not  need  this  complicated,  isolated  injection  of  the  peritoneum,  because 
he  used  stronger  cocain  solutions  than  Schleich.  After  one  effective  injection  of  the 
anesthetic  solution  into  the  subserous  tissue,  the  peritoneum,  which  receives  its 
innervation  from  this  tissue,  naturally  becomes  insensitive  just  as  the  skin  becomes 
insensitive  after  injections  into  the  subcutaneous  cellular  tissue. 


Fig.   128. — Injection  for  gastrostomy  and  the  circuminjection  of  the  upper  abdominal  region.      (White.) 


The  anesthetic  technique  used  at  the  present  time  for  incisions  of  the  abdominal 
wall  is  both  simple  and  effective.  The  narrowness  of  the  anesthetized  zone  obtained 
by  Schleich's  method  and  the  short  duration  of  the  anesthesia  were  troublesome 
factors  and  prevented  the  general  use  of  local  anesthesia  in  abdominal  operations. 
Even  though  these  inconveniences  can  be  avoided  now,  the  advancement  which  has 
been  made  since  Schleich's  time  in  local  anesthesia  for  abdominal  operations,  hernia 
excepted,  is  much  less  important  than  in  many  other  operative  fields. 


ABDOMIXAL  OPERATIONS  299 

Gastrostomy.  This  is  a  splendid  field  for  local  anesthesia,  l)ecaiis(>  only  the 
abdominal  layers  need  l)e  anesthetized;  there  are  no  abdominal  sensations  with  which 
to  contend,  nor  is  there  any  need  of  additional  anesthesia.  Only  a  narrow  anesthetized 
zone  is  necessary  and  the  operation  is  of  short  duration.  For  this  reason  Schleich's 
anesthesia  is  specially  suitable  for  this  operation. 

Two  points  of  entrance  are  marked  (Fig.  128),  one  close  to  the  edge  of  the  ribs, 
and  the  other  at  a  point  corresponding  wdth  the  lower  end  of  the  contemplated  incision. 
From  these  two  points  the  abdominal  layers  are  injected  according  to  the  plan  of 
Fig.  29  (page  189) .  A  long  needle  is  inserted  from  each  of  these  points  perpendicularly, 
then  obliquely,  constant  injection  being  made  through  the  skin,  subcutaneous  cellular 
tissue  and  the  rectus  muscle  into  the  preperitoneal  tissue,  and  finally  injection  is 
made  from  point  to  point,  just  under  the  skin.  This  sounds  dangerous,  but,  on  the 
contrary,  the  operator  can  feel  exactly  w^hich  layer  of  the  abdominal  wall  is  being 
penetrated  by  the  needle,  and  the  resistance  ofl^ered  to  the  point  of  the  needle  by  the 
sheath  of  the  rectus  muscle  can  be  distinctly  felt.  For  this  procedure  40  to  50  c.c. 
of  0.5  per  cent,  novocain-suprarenin  solution  is  needed.  In  these  cases  only  the 
simple  infiltration  anesthesia  is  used,  and  it  is  scarcely  necessary  to  mention  that 
the  method  just  described  is  a  simplified  anfl  modified  Schleich  method. 

Other  Operations  in  the  Upper  Part  of  the  Abdomen. — Of  all  the  abdominal  opera- 
tions that  can  be  performed  inider  local  anesthesia  through  a  median  incision  the  most 
suitable  are  the  stomach  operations  in  w^eak  individuals,  such  as  gastro-enterostomy, 
pylorus  resections  and  some  exploratory  laparotomies,  in  which  it  is  unnecessary 
to  explore  the  entire  abdominal  cavity.  But  in  these  cases  local  anesthesia  can  only 
be  used  with  some  additional  general  anesthetic.  In  laparotomies  where  the  abdomi- 
nal w^all  must  be  stretched  with  retractors  and  where  packing  is  necessary,  anesthesia 
of  the  abdominal  layers  in  the  line  of  incision  wull  not  be  sufficient.  Naturally  much 
better  results  are  obtained,  if  as  broad  a  strip  of  peritoneum  as  possible  is  anesthetized 
both  to  the  right  and  left  of  the  line  of  incision.  This  is  easily  accomplished  by  cir- 
cuminjection.  Five  points  of  entrance  are  marked,  as  shown  in  Fig.  126.  The  four 
lateral  points  lie  on  the  outer  edge  of  the  rectus;  every  line  joining  two  points  is 
infiltrated  according  to  the  scheme  of  Fig.  29  (page  189);  100  to  150  c.c.  of  0.5  per 
cent,  novocain-suprarenin  solution  is  necessary. 

Recently  excellent  results  have  been  obtained  by  injecting  subcutaneously  a  bilateral 
strip  from  the  ensiform  process  to  the  external  border  of  the  rectus  and  under  the 
rectus.  Furthermore,  both  sides  of  the  outer  border  of  the  rectus  are  injected 
downward  subcutaneously  and  subfascially.  A  0.5  per  cent,  novocain-suprarenin 
solution  is  used.  Following  this  injection  the  abdominal  layers  become  insen- 
sitive as  far  as  the  umbilicus  and  at  the  same  time  the  recti  become  relaxed 
(Fig.  129). 


300 


LOCAL  ANESTHESIA 


Gastro-enterostomy  is  performed  in  the  following  manner:  About  one  to  one  and 
a  half  hours  before  the  beginning  of  the  operation,  0.0005  scopolamin  and  0.01  mor- 
phium  are  administered.  The  circuminjection  of  the  upper  abdominal  region  is  next 
carried  out  as  described.  While  the  abdomen  is  being  opened  the  patient  receives 
some  general  anesthesia  until  the  condition  and  position  of  the  abdominal  contents 
have  been  ascertained,  the  stomach  and  intestines  have  been  packed  off,  after  which 
the  patient  is  not  given  any  more  general  anesthetic.  In  abdominal  operations,  ether 
anesthesia,  in  connection  with  local  anesthesia,  has  up  to  the  present  time  been  con- 
sidered the  most  suitable.  From  recent  observations,  ethyl  chlorid  anesthesia, 
according  to  Kulenkampff,^  can  be  recommended  for  this  purpose. 


11  fur  incisions  above  the  umbilicus. 


The  ethyl  chlorid  is  dropped  from  the  customary  glass  tube  upon  several  folded    j 
compresses  which  cover  the  mouth  and  nose  of  the  patient.    After  a  few  inhalations   j 
the  desired  analgesia  sets  in,  and  the  patient  awakens  immediately  upon  the  removal 
of  the  inhaler.     This  form  of  anesthesia  used  in  conjunction  with  local  anesthesia 
is  specially  suitable  on  account  of  the  quickness  with  which  the  analgesic  effect  is 
obtained  and  the  absence  of  any  irritation  of  the  organs  of  respiration  or  the  cortex  of 
the  brain.    In  resection  of  the  pylorus  the  method  is  the  same,  but,  as  a  rule,  a  second 
anesthesia  is  necessary  in  tying  off  the  lesser  omentum  and  sometimes  for  removing   I 
the  packing.  i 

There  is  no  doubt  that  patients  treated  in  this  manner  leave  the  operating-table 
in  an  incomparably  better  condition  than  if  they  had  been  subjected  to  a  prolonged 

1  Kulenkampff:    On    the   Analgesic  Stage  of  Ethyl  Chlorid  Anesthesia,   Beitnige  zur  klin.  Chirurgie,     I 
1911,  Bd.  Ixxiii,  384.  '  | 

I 


AHDOMIXAL   OI'Klx'ATlOXS  :\{)\ 

jiviuTal  aiK'stlu'sia.  Tlu'  freedom  from  (laiii;vr  of  the  anesthetic  can  in  no  way  he 
hetter  understocxl  than  hy  freqnent  ohservation  of  this  proce(hire.  Patients  very 
ill  with  stenosis  t)f  the  pylorus  endure  a  reseetion  of  the  pylorus  without  experiencing 
e\en  a  transient  ill  effect  upon  their  general  condition,  and  it  is  unnecessary  to  give 
salt  infusions,  etc.  The  author  therefore  heartily  agrees  with  Bakes  and  Laewen 
who  predict  decided  progress  in  operative  technique  by  the  use  of  combined  local 
and  general  anesthesia.  This  progress  will  be  due  not  so  much  to  improvement  in 
the  technique  of  local  anesthesia  as  to  the  more  skilful  use  of  the  general  anesthesia. 
This  method  of  anesthesia  is  suitable  for  all  abdominal  operations  of  short  dura- 
tion and  is  particularly  commendable  in  weak  and  debilitated  patients,  for  in  them 
results  are  better  than  in  stronger  persons  who  are  able  to  fight  against  the  anesthetic. 

For  operations  on  the  bile-ducts  general  anesthesia  is  recommended  because  they 
are  almost  entirely  intra-abdominal.  On  the  other  hand,  simple  local  anesthesia 
is  used  to  great  advantage  in  opening  abscesses  of  the  liver  and  for  echinococcus 
cysts.  The  infiltration  is  done  as  in  gastrostomy,  along  the  line  of  incision,  no  matter 
what  direction  the  incision  is  to  take. 

Median  Incisions  in  the  Lower  Abdomen. — There  are  only  a  few  operations  for 
which  simi)le  local  anesthesia  or  the  combined  method  can  be  considered,  viz.:  for 
evacuation  of  ascitic  fluid  of  tuberculous  origin,  or  occasional  cases  of  extirpation 
of  an  ovarian  tumor  without  adhesions.  Tsually  it  is  only  necessary  to  infiltrate 
in  the  line  of  incision  from  two  points  of  entrance,  one  at  the  upper  and  one  at  the 
lower  end  of  the  small  median  incision,  and  to  infiltrate  first  the  preperitoneal  and 
then  the  subcutaneous  tissue  with  a  0.5  per  cent,  novocain-suprarenin  solution. 

Anesthesia  of  the  Ileocecal  Region. — The  ileocecal  region  is  circuminjected  from 
four  points,  as  shown  in  Fig.  \'M).  The  injection  from  point  2  toward  point  1  is  of 
special  importance,  because  this  area  contains  all  the  innervation  supplying  the 
field  of  operation.  The  infiltration  along  the  line  1  to  2  should  be  performed  accord- 
ing to  the  scheme  in  Fig.  27,  a  section  of  the  tissues  extending  to  the  peritoneum. 
For  the  completion  of  the  injection  it  is  only  necessary  to  infiltrate  in  the  direction 
of  the  dotted  line,  passing  the  needle  subcutaneously  and  under  the  aponeurosis 
parallel  with  the  surface  of  the  skin;  100  c.c,  and  in  fat  subjects  120  c.c.  of  0.5  per 
cent,  novocain-suprarenin  solution  will  be  required.  The  result  is  a  complete  anes- 
thesia of  the  abdominal  layers  and  of  the  parietal  peritoneum  as  low^  as  the  ileocecal 
fossa. 

This  method  is  suitable  for  certain  cases  of  appendicitis,  cecostomy,  and  for  closure 
of  intestinal  fistulte.  On  the  left  side  for  making  and  closing  an  artificial  aiuis  the 
method  is  the  same.  For  cecostomy,  simple  infiltration  in  the  line  of  incision  is 
sufficient.  If  there  is  much  meteorism,  it  is  well  to  observe  the  thinning  of  the 
abdominal  layers,  to  avoid  entering  the  abdomen  with  the  point  of  the  needle  while 


302 


LOCAL  ANESTHESIA 


making  the  subaponeurotic  injection.  Intestinal  fistulse  and  artificial  ani  can  easily 
be  circuminjected  as  far  as  the  preperitoneal  tissue,  if  a  guiding  finger  is  inserted 
into  the  bowel. 

In  operations  for  appendicitis,  infiltration  of  the  line  of  incision  will  not  be  sufficient. 
Hesse  and  Stenglein  have  reported  on  the  use  of  local  anesthesia  in  appendicitis. 
Hesse  considers  it  suitable  in  (1)  all  cases  operated  in  the  interval  between  attacks, 
(2)  mild  chronic  cases,  (3)  light  or  severe  cases  early  in  the  first  attack.  In  the  follow- 
ing cases  local  anesthesia  is  contra-indicated  (1)  in  practically  all  abscesses;  (2)  all 
cases  in  which  a  complicated  pathological  anatomy  is  to  be  expected. 


Fig.   130. — Appendectomy 


When  the  above-described  circuminjection  has  been  properly  carried  out,  the  incis- 
ion through  the  abdominal  layers,  no  matter  in  which  direction  the  incision  was  made, 
as  well  as  the  stretching  of  the  abdominal  wound  and  the  packing  become  painless. 
Localized  abdominal  sensations  arise  most  frequently  in  the  epigastrium  whenever 
adhesions  are  separated,  when  traction  is  made  on  the  cecum  or  when  the  mesenterio- 
lum  is  ligated.  Hesse  advises  that  the  mesentery  be  infiltrated  before  it  is  ligated, 
but  this  only  lessens  in  small  part  the  abdominal  sensations.  They  are  best  con- 
trolled by  morphium-scopalamin,  as  Stenglein  suggests,  or  if  necessary  by  the  addition 
of  ethyl  chlorid  anesthesia  during  the  search  for  and  the  isolation  of  the  appendix. 
The  advantages  derived  from  these  combinations  are  not  so  apparent  in  appendicitis 


ABDOMINAL  OPERATIONS  1 50: 5 

operations,  as  they  are  in  stomach  operations,  inasmuch  as  the  indications  and  contra- 
indications which  Hesse  mentioned,  are  often  not  recognized  until  the  operation  is  in 
progress.^ 

OPERATIONS    FOR    HERNIA. 

All  things  considered,  it  may  be  stated  generally  that  local  anesthesia  or  the  com- 
bined method  is  of  no  special  importance  in  abdominal  operations,  except  stomach 
operations,  and  the  few  others  above  mentioned.  In  hernia  operations  the  situation 
is  entirely  different,  for  here  local  anesthesia  should  be  the  method  of  choice,  as  it  is 
suitable  for  all  operations.  The  abdominal  sensations  in  these  cases  are  very  slight. 
Since  the  introduction  of  cocain,  local  anesthesia  has  been  considered  particularly 
suitable  for  hernia  operations  and  has  been  used  with  more  or  less  success.  Every 
author  who  refers  to  this  subject  gives  favorable  reports,  and  as  early  as  1889  Reclus 
used  local  anesthesia  in  the  majority  of  hernia  operations.  He  designates  the  opera- 
tion for  strangulated  hernia  **the  triumph  of  cocain."  He  states  that  this  is  the 
anesthesia  of  choice,  and  in  his  judgment  the  use  of  general  anesthesia  is  justifiable 
only  under  special  conditions,  such  as  hernise  of  very  large  size,  extensive  adhesions, 
or  the  probability  of  complications. 

Schleich's  infiltration  anesthesia  was  considered  a  step  in  advance  for  local  anes- 
thesia as  the  large  doses  of  cocain  used  by  Reclus  w^ere  no  longer  necessary;  but 
it  is  an  undeniable  fact  that  this  progress,  at  least  in  inguinal  and  femoral  hernia, 
was  made  at  the  risk  of  producing  an  uncertain  anesthesia.  The  branches  of  the  ilio- 
inguinal, the  spermatic,  and  the  iliohypogastric  nerves  remain  painful  and  capable 
of  conduction,  no  matter  how  freely  the  tissues,  in  which  they  lie,  are  infiltrated  with 
the  Schleich  solution.  For  this  reason  Gushing  recommends  that  in  operations  for 
inguinal  hernia  the  search  for  the  nerve  trunks  which  enter  the  field  of  operation 
should  not  be  made  until  after  the  fascia  of  the  external  oblique  muscle  has  been  cut, 
and  that  they  be  blocked  b}'  an  endoneural  injection  of  a  1  per  cent,  cocain  solution. 
Hackenbruch,  starting  out  with  an  entirely  different  principle  from  Reclus  and 
Schleich,  injected  the  cocain-eucain  solution  in  a  fork-shaped  or  diamond-shaped 
area  around  the  hernial  ring. 

All  these  methods  have  been  superseded  at  the  present  time  and  are  now  of  only 
historical  value.  They  proved  unreliable  and  difficult  and  their  success  depended 
too  much  upon  the  size  of  the  hernia  and  other  anatomical  conditions.  For  this 
reason  the  use  of  local  anesthesia  for  hernia  remained  in  the  hands  of  a  few  specialists. 

^  The  writer  confesses  that  after  many  attempts,  some  of  them  dating  back  a  long  time,  he  always 
returns  to  the  same  conclusion,  that  is,  to  perform  operations  on  the  appendix  under  general  anesthesia 
without  local   anesthesia. 


ii_ 


304 


LOCAL  ANESTHESIA 


But  there  has  been  a  great  change  since  the  advent  of  new  anesthetizing  sokitions, 
with  their  simplified  technique,  and  their  greater  reliabiHty.    In  most  of  the  surgical 


/ 


%e 


y  --. 


\ 


Fig.    181.— Anesthesia  for  uiiilHlical  hernia. 


hospitals  of  Germany,  hernias  are  now  operated  upon  under  local  anesthesia  according 
to  the  method  described  by  Nast-Kolb,  von  Lictenberg,  and  Braun. 

Statistical  reports  have  been  made  on  this  subject  by  Hesse  from  city  hospital 


ABDOMINAL  OPERATIONS 


305 


at  Stettin,  where  21S  hernia  operations  were  performed  from  .January  1,  1909,  to  Sep- 
tember 15,  1910,  of  whieh  170  were  performed  under  local  anesthesia,  and  48  under 
general  anesthesia.  In  the  hospital  at  Zwickau  there  were  397  cases  operated  for 
hernia  from  January  1, 1909,  to  October  1,  1911,  and  of  these  cases  345  were  operated 
under  local  and  52  under  general  anesthesia.  It  has  already  been  mentioned  on  page 
171  that  childhood  presents  no  contra-indication  to  the  use  of  local  anesthesia  in 
hernia  operations;  children  are  easily  influenced,  and  if  they  can  be  induced  to  allow 
the  injection,  no  further  anesthesia  will  be  required.  During  the  operation  it  will,  of 
course,  be  necessary  for  some  experienced  person  to  entertain  the  child. 


Fig.   132. — Cross-section  of  an  umbilical  hernia  to  demonstrate  the  extent  of  the  deep  injection. 


Operations  for  Umbilical  Hernise,  Hernia  of  the  Linea  Alba,  and  Postoperative 
Hernia.— The  abdominal  wall  is  anesthetized  on  the  same  principle  as  described 
for  abdominal  incisions  above  the  umbilicus  or  ileocecal  region.  Four  or  more  points 
of  injection  are  marked.  Surrounding  the  field  of  operation  (Figs.  131  and  132)  and 
proceeding  from  these  the  abdominal  wall  is  circularly  infiltrated  down  to  the  pre- 
peritoneal tissue  with  a  0.5  per  cent,  novocain-suprarenin  solution.  This  is  exceed- 
ingly simple  and  easily  done  in  a  reducible  hernia,  in  which  case  the  left  index  finger 
is  introduced  into  the  ring,  and,  guided  in  this  w^ay,  the  injection  is  made.  After  a 
little  experience  this  can  be  done  just  as  well  in  irreducible  and  strangulated  hernia. 
In  these  cases,  however,  the  operator  must  not  expect  to  infiltrate  the  ring,  for  in 
20 


306  LOCAL  ANESTHESIA 

irreducible  hernia  it  is  not  accessible.  He  must  rather  aim  to  infiltrate  a  layer  of  the 
abdominal  wall  at  some  distance  from  the  hernial  swelling.  This  will  cause  the 
entire  hernia  to  become  insensitive.  The  greatest  amount  of  anesthetic  necessary 
in  large  umbilical  hernise  in  fat  persons  is  250  c.c.  of  a  0.5  per  cent,  novocain-supra- 
renin  solution.  Before  undertaking  a  case  of  this  kind  it  is  necessary  to  know  just 
how  to  guide  the  needle.  In  very  fat  persons  it  is  advisable  at  first  to  infiltrate 
the  skin  and  the  subcutaneous  connective  tissue  close  to  the  hernial  swelling;  the 
aponeurosis  is  then  exposed  to  the  right  and  left  of  the  hernial  mass.  The  sub- 
aponeurotic injection  can  now  be  easily  made  as  described;  it  is,  however,  necessary 
to  wait  until  the  peritoneum  and  hernial  sac  become  insensitive.  This  method  can 
be  used  in  all  cases  of  umbilical  hernia,  except  when  jNIenge's  radical  operation  is 
required,  in  which  case  local  anesthesia  is  not  advisable. 

Hernise  of  the  linea  alba  are  anesthetized  in  the  same  way  as  the  median  incision 
for  stomach  operations  (page  113),  the  size  of  the  circuminjected  area  depending 
upon  the  extent  of  the  field  of  operation.  Most  postoperative  hernise  can  be  easily 
operated  upon  under  local  anesthesia  by  circuminjection. 

Operations  for  Inguinal  Hernia. — The  object  of  the  injection  technique  is  to  block 
the  nerve  trunks  supplying  the  field  of  operation  before  they  reach  it,  and  to  circum- 
inject  the  field  of  operation.    Neither  of  these  manipulations  alone  would  be  suflficient. 
Fig.  133  explains  schematically  the  innervation  of  the  inguinal  and  femoral  region.  | 
The  external  spermatic  nerve,  which  is  a  branch  of  the  genitofemoral,  joins  the  I 
spermatic  cord  at  the  internal  ring,  and  accompanying  it  emerges  from  the  inguinal   ^ 
canal  on  the  under  surface  of  the  cord  to  be  distributed  to  the  cremaster  muscle,   ^• 
tunica  dartos,  the  skin  of  the  scrotum  or  the  labia  majora,  as  well  as  the  thigh  in  the    ' 
region  of  the  external  ring. 

The  ilio-inguinal  nerve  lies  above  the  spine  of  the  ilium,  between  the  oblique  abdom- 
inal muscles;  passing  under  the  fascia  of  the  external  oblique  it  leaves  the  inguinal 
canal  on  the  anterior  surface  of  the  hernial  sac  or  the  spermatic  cord.     Branches 
of  this  nerve  supply  the  skin  of  the  thigh,  the  scrotum  and  pubic  eminence.    The  .| 
iliohypogastric  nerve  runs  almost  parallel  with  and  a  little  higher  than  the  former, 
between  the  oblique  abdominal  muscles,  and  in  the  inguinal  region  under  the  fascia    i 
of  the  external  oblique  muscle.     It  penetrates  the  anterior  sheath  of  the  rectus,  in    | 
this  manner  reaching  the  subcutaneous  connective  tissues,  innervating  the  skin  of  the    [ 
inguinal  region.    The  three  nerves  anastomose  with  one  another;  one  or  two  of  them 
may  be  absent,  in  which  case  they  can  be  replaced  one  by  the  other.    Bodine  declares 
that  the  iliohypogastric  nerve  is  the  most  constant  one  and  not  infrequently  sends  a 
branch  through  the  inguinal  canal,  thus  replacing  a  branch  of  the  ilio-inguinal. 

The  ilio-inguinal  and  the  external  spermatic  can  also  replace  one  another.     The    j 
lumbo-inguinal,  which  is  more  deeplv  seated,  is  scarcelv  taken  into  consideration  in  | 

i 


A BDOMIXA L  OI'Kh'A  TJOXS 


307 


operations  for  inguinal  hernia.    Gushing  has  called  attention  to  the  fact  that  if  the 
three  nerves  first  mentioned  are  cocainized  at  their  entrance  into  the  inguinal  canal, 

the  greater  ])art  of  the  field  of  operation  will  become  insensitive. 


Fig.  133. — laucrvatioii  of  the  inguinal  and  femoral  region  1,  gonitociiiial  nerve;  2,  external  spermatic 
nerve;  3,  lumbo-inguinal  nerve;  4,  ilio-inguinal  nerve;  5,  iliohypogastric  nerve;  6,  anterior  cutaneous  branches 
of  the  twelfth  intercostal  nerve. 


Method  Used  in  Reducible  Inguinal  Hernia. — ^Two  points  of  entrance  are  marked 
(Fig.  134).  Point  1  lies  three  finger-breadths  internal  to  the  anterior  superior  spine 
of  the  ilium.  Point  2  is  exactly  over  the  horizontal  ramus  of  the  pubes  at  the  outer 
inguinal  ring.  From  point  1  the  muscular  layer  (arrow  A)  lying  between  the  point 
of  injection  and  the  ilium  is  infiltrated  according  to  Fig.  29  (page  190).  About  20  c.c. 
of  a  0.5  per  cent,  novocain-suprarenin  solution  is  injected  in  the  following  manner 
(Figs.  135  and  136) :  The  long  needle  is  first  entered  perpendicular  to  the  surface  of 
the  skin,  then  through  the  aponeurosis  of  the  external  oblique  muscle  and  through 
the  muscular  layers  of  the  internal  oblique  and  transverse  muscles;  it  is  then  with- 
drawn and  inserted  twice  again,  each  time  in  a  more  oblique  direction  toward  the 


308  LOCAL  ANESTHESIA 

spine  of  the  ilium,  until  the  point  of  the  needle  strikes  the  iliac  bone.    The  thick 
muscular  layer  situated  in  this  region  must  be  infiltrated.    This  injection  blocks  the 


Fig.   134. — Injection  for  reducible  inguinal  hernia.     The  dotted  lines  indicate  subaponeurotic 
injections,  the  continuous  lines  the  subcutaneous  injections. 


ilio-inguinal  and  the  iliohypogastric  nerves.    From  point  1  further  injection  of  10  to 
20  c.c.  of  0.5  per  cent,  novocain-suprarenin  solution  is  made  under  the  aponeurosis 


.1 HDOM I  .V.  I L  OPERA  TIONS 


309 


of  the  external  oblique  muscle  in  a  fork-sliai)e(l  inaniicr  toward  a  i)()int  lying  in  the 
median  line,  laterally  from  the  inguinal  ring  (arrows  b  and  r). 


Fig.  135. — Cross-section  ^ 
from  frozen  section.)  a,  glut 
and  internal  oblique  and  tra 
and  ilio-inguinal  nerves  is  .s^ 


r  .superior  spine  of  the  ilium.  (Made 
rectus  abdominus  muscle;  e,  external 
ink  or  branches  of  the  iliohypogastric 


From  point  2  a  deep  injection  of  10  c.c.  of  the  solution  is  made  in  a  fan-shaped  man- 
ner, and  with  each  injection  the  needle  will  strike  the  pubic  bone.  From  point  2 
further  injections  of  10  c.c.  are  made  in  a  fork-shaped  manner  under  the  aponeurosis 
in  the  inguinal  canal  along  the  spermatic  cord  (arrows  d  and  e).  The  skin  incision 
is  finally  circuminjected  subcutaneously  in  the  form  of  a  rhombus,  75  to  100  c.c.  of 
0.5  per  cent,  novocain-suprarenin  solution  being  necessary  for  the  entire  injection. 
In  double  hernia  both  sides  are  injected  before  the  operation  is  begun. 


310 


LOCAL  ANESTHESIA 


Method  of  Operation  in   Irreducible   or    Strangulated   Inguinal   Herniae. — The 

position  of  the  points  of  injection,  as  well  as  the  subcntaneous  and  subaponeurotic 
or  subfascial  strip  of  injection  is  shown  in  Figs.  137  and  138.  From  point  1  the  injec- 
tions are  made,  as  already  described,  toward  the  iliac  spine,  then  follow  the  sub- 
aponeurotic injections  toward  points  2  and  3.  These  are  followed  by  deep  injections 
from  points  2  and  3,  the  hernial  mass  being  held  up  with  the  left  hand,  either  to  the 
outside  or  inside  as  the  case  requires.  From  both  of  these  points,  the  needle  must 
reach  the  pubic  bone  underneath  the  hernial  mass.  Further  injections  are  made 
from  points  2  and  3  under  the  aponeurosis  into  the  inguinal  canal,  alongside  the  neck 


Fig.   136. — Guidance  of  the  needle  for  injections  near  the  iliac  spine  in  inguinal  and  femoral  herniffi. 


of  the  hernial  sac.  The  final  injection  is  a  subcutaneous  one  between  points  1,  2,  3, 
and  a  subcutaneous  circuminjection  of  the  whole  scrotum  and  penis  as  the  diagram 
shows.  In  very  large  herniae  150  c.c.  of  0.5  per  cent,  novocain-suprarenin  solution 
will  be  necessary.  Reducible  hernise,  with  large  sacs  reaching  to  the  base  of  the 
scrotum,  are  also  better  managed  in  the  way  just  described,  that  is,  by  circum- 
injecting  the  entire  scrotum. 

Procedure  in  Femoral  Hernia.— A  glance  at  Fig.  133  will  show  that  the  field  of 
operation  for  femoral  hernia  is  mainly  innervated  by  the  same  nerve  trunks  which 
played  an  essential  part  in  the  anesthesia  of  the  field  of  operation  for  inguinal 
hernia   operations.     Anesthesia   for  femoral   hernia   is   produced   in   the   following 


311 


.ib/«m;;,v.i;-  orniiATinNS 

„.,■  ll-ii;.  1?.!)).   'riK-re  -.m-  Icui-  points  to  he  mark..l  l.x  wIhmIs.    I'oiiit  1  ..ccupies 


[lie    «unr    p,.siti.m  \,s    it    dors    in    operations    for    ins;uinal    l.rrnia,    tl.roc    finger- 


breadths  fron,  tl>e  spine  ot  the  ilinn,  to.ar.l  the  median  Hne.    ^-^^l"'^^ 
each  side  of  the  hernial  mass  an.l  at  the  ends  ot  the  nu-.s.on  to  ^e  ma^e   .h    h 
parallel  to  Fouparfs  ligament.    Point  4  lies  underneath  the  hern.al  mass.    \\e  be.tn 


312 


LOCAL  ANESTHESIA 


with  the  intramuscular  injections  from  point  1,  which  should  be  directed  toward 
the   spine  of  the   ilium  as  they  were  in  the  case  of  inguinal  hernia,  then  a  fork- 


FiG.  138. — Continuation  of  the  injection  as  shown  in  Fig.  137. 


shaped,  subfascial  injection  from  point  1  is  made,  passing  the  needle  on  each  side  | 
of  the  hernial  sac  as  far  as  Poupart's  ligament.  From  point  4,  10  c.c.  of  novocain-  1 
suprarenin  solution  is  injected  in  the  region  of  the  neck  of  the  hernial  sac,  as  close  to     \ 


ABDOMINAL  01' ERA  TIONS 


313 


it  as  possible,  and  finally  a  subcutaneous  circuminjection  is  made,  as  indicated  by 
the  line  drawn  in  the  diagram.  The  operations  are  entirely  painless  and  no  further 
injections  will  be  necessary  for  the  radical  o])erati()n,  even  if  the  complication  arises 


which  necessitates  the  cutting  of  Poupart's  ligament  upward.  The  same  method 
used  for  inguinal  operations  can  also  be  used  for  femoral  hernia  without  any  change. 
In  the  method  of  anesthesia  the  size  and  consistency  of  the  hernia  need  not  be  taken 


314  LOCAL  ANESTHESIA 

into  consideration,  whether  it  be  reducible  or  irreducible,  strangulated  or  not.  No 
difficulties  are  encountered  in  this  anesthesia,  except  occasionally  in  obese  and  excit- 
able patients.  In  the  latter  case  morphium  or  morphium-scopolamin  should  be  given. 
Other  patients  need  not  be  prepared  by  the  administration  of  any  opiate.  Abdominal 
sensations  seldom  occur  except,  perhaps  once  in  a  great  while,  when  a  hernial  sac 
is  separated  and  drawn  out,  and  occasionally  in  gangrenous  hernia  when  the  mesen- 
tery is  ligated.  They  are  bearable,  and  only  in  exceptional  cases  is  it  necessary  to 
use  ethyl  chlorid. 


chaptp:k  XV. 

GEXITO-URINARY  AND  RECTAL  OPERATIONS. 

The  Innervation. — The  innervation  of  the  organs  of  the  pelvis,  and  to  some  extent 
that  of  the  external  genitalia,  is  supplied  by  the  piidic  nerves,  pelvic  branches  of  the 
posterior  cutaneous  femoral,  by  spinal  nerves,  originating  in  the  sacral  plexus  which 
accompany  the  sympathetic  nerve  bundles  of  the  pelvic  organs,  and  by  the  nerves  of 
the  coccygeal  plexus.  Their  distribution  in  the  perineum  and  the  external  genitalia 
can  be  seen  from  Figs.  140  and  141.  The  trunk  of  the  pudic  nerve  emerges  from 
the  pelvis  through  the  large  ischiatic  foramen,  passes  along  the  outer  surface  of  the 
spine  of  the  ischium  to  be  divided  into  its  branches,  which  again  enter  the  pelvis 
between  the  tuberosity  and  the  spine  of  the  sacrum. 

Fig.  142  shows  the  position  of  the  nerve  trunk  on  the  outer  surface  of  the  spine 
of  the  ischium.  Its  branches  lie  in  the  ischiorectal  fossa  and  supply  the  skin  of  the 
perineum,  parts  of  the  anus,  the  skin  of  the  posterior  surface  of  the  scrotum,  the  urethra 
and  corpora  cavernosa,  the  penis,  in  females  the  labia  minora,  the  greater  part  of  the 
vagina,  and  a  part  of  the  labia  majora.  The  pelvic  branches  of  the  posterior 
cutaneous  femoral,  and  the  nerves  which  pass  through  the  inguinal  canal  supply  the 
anal  region  and  the  perineum,  the  skin  of  the  scrotum  and  the  labia  majora;  the  nerves 
originating  from  the  coccj^geal  plexus  also  supply  the  anal  region.  The  spinal  nerves, 
known  as  the  pelvic  nerves,  originate  from  the  second,  third,  and  fourth  sacral  nerves, 
run  forward  on  both  sides  of  the  rectum,  and  in  the  female  unite  with  the  sympathetic 
ganglion  (ganglion  cervicale  uteri.  Fig.  143)  which  lies  between  the  cervix  uteri  and 
the  rectum.    In  the  male,  it  lies  laterally  between  the  prostate  and  the  rectum. 

The  pelvic  nerve  innervates  the  bladder,  uterus,  prostate  and  the  upper  part  of 
the  rectum,  as  well  as  the  lower  part  of  the  pelvic  peritoneum.  The  sympathetic 
ganglion  itself  takes  no  part  in  the  sensory  innervation  of  these  parts. 


CONDUCTION    ANESTHESIA    IN    THE    PELVIS. 

Ilmer  has  recommended  for  operations  on  the  female  genitalia  and  for  confine- 
ments that  the  trunk  of  the  pudic  nerve  be  blocketl  on  both  sides  by  injections  of 
5  to  10  per  cent,  cocain  sohition.    The  anesthesia  used  l)y  him  is  absolutely  unreliable 


316 


LOCAL  ANESTHESIA 


and  dangerous.    Hmer  relies  upon  the  methods  of  B.  Mueller,  which  appear  to  be 
altogether  theoretical  and  not  at  all  based  on  practical  experience.    For  example,  an 


Fig.   I40.-Nervesof  thonudopennc.u,n(aiterToldt).    ^'.^^^^ ^^  ;Z::J£'te^n^^^^  ^ 

nosun.  urothr.;  4    i->^i"-vo.-nous  musd,.   .^^  ,,^  | 

mu.clo;  7,  ponno.,1  n.Mvo    ^    ''"r'    ^  ^     /  V,,' ,;,;^  ,,,rosum;    13,  anococcygei  nerves;    14,  levator  am  ' 

sphincter  an.  .  mmum-  n, u^-  .        -    L-      '  ,„or,hoidal  nerve;   17,  ischiorectal  fossa;   18,  perineal 

nitric- 'l')^''.< ..'.'.'  '.rinuM  l''^  uM.-t'  ■„'.  ,  ui  m.  u^  h  inoris  nerve;  20,  branches  of  perineal  nerve;  21,  trans- 

vcrsus  pcrinci  piotuiidu-  iim-clc  22.  po-t-ciot.il  iicn  es.  i 

extensive  anesthesia,  which  Mueller  recommends  should  be  done  by  blocking  both  | 

pudic  trunks,  cannot  be  accomplished.     Furthermore,  the  operator  cannot  always  | 

1 


GENirO-UBIXARY  AM)  RECTAL  OPERATIONS 


317 


rely  upon  meeting  the  trunk  of  the  nerve  on  the  inner  surface  of  the  pelvis,  because 
it  is  covered  by  the  obturator  fascia  and  divides  before  its  entrance  into  the  ischio- 


FiG.  141.— Nerves  of  the  female  perineum.  (After  Toldt.)  1,  mons  pubis;  2,  dorsalis  chtoridis  nerve; 
3  posterior  labial  nerves;  4,  perineal  branches  of  the  cutaneus  femoris  posterior;  5,  perineal  nerve;  b, 
profundus  hemorrhoidal  nerve;  7,  anococcygei  nerves;  8,  coccygeus  muscle;  9,  gluteus  maximus  muscle; 
10,  ischiorectal  fossa;  11,  levator  ani  muscle;  12,  sphincter  ani  externus  muscle;  13,  transversus  perinei 
profundus  muscle;  15,  ischiocavernous  muscle;  15,  bulbocavernosus  muscle;  16,  labium  majus;  17,  clitoris. 


rectal  fossa.  For  this  reason  Franke  and  Posner  recommend  that  search  be  made  for 
the  nerve  on  the  outer  surface  of  the  spine  of  the  ischium  (Fig.  142),  where  it  lies  in 
the  loose  connective  tissue.     Guided  by  a  finger  placed  in  the  rectum,  they  insert  a 


318 


LOCAL  ANESTHESIA 


needle  15  cm.  long  from  a  point  on  the  side  of  the  anus,  until  the  spine  of  the  ischium 
is  felt,  and  then  direct  the  needle  backward  to  the  outer  surface  of  the  bone.  It  is 
sometimes  difficult  to  feel  the  spine  of  the  ischium  and  reach  it  with  a  needle  when 
inserted  so  deeply.  Blocking  the  trunk  of  the  pudic  nerve  alone  without  the  pos- 
terior cutaneous  femoral,  the  coccygeal  plexus,  and  the  pelvic  nerve,  is  of  little  value. 
It  is  much  easier  to  exclude  its  branches  by  proper  injections,  as  will  be  seen  later. 


.Jit  m.-\ 


Fig.   142. — Position  of  the  pudic  nerve  on  the  spine  of  the  ischium. 


The  pelvic  branches  of  the  posterior  cutaneous  femoral  are  easily  blocked,  together 

with  the  branches  of  the  pudic  nerve,  by  injections  into  the  ischiorectal  fossa,  and  the  | 

coccygeal  plexus  is  found  by  making  an  injection  between  the  coccyx  and  the  rectum.  | 

Franke  and  Posner  attempted  to  locate  the  pelvic  nerve  by  making  injections  in  the  | 

region  of  the  sympathetic  ganglion  of  the  cervix  of  the  uterus  (Fig.  143).    For  this  | 

purpose  a  needle  15  cm.  long  was  inserted  at  a  point  in  front  and  to  the  side  of  the  j 

anus,  between  the  rectum  and  the  prostate,  as  high  as  the  region  of  the  ganglion,  i 


GENITO-l'h'IXAin'    AM)   RECTAL   Ol'Kh'ATlOXS 


319 


injecting  15  c.c.  of  1  per  cent,  novocain-suijrarciiin  solution  on  both  sides.  In  con- 
nection with  the  above-nanieci  injection  of  the  trunk  of  the  pudic  nerve,  antl  injections 
into  the  ischiorectal  fossa,  they  were  able  to  make  painless  perineal  prostatectomies 
and  one  lithotripsy.    It  is,  however,  more  important  and  technically  much  simpler 


(After  Corning.) 


to  block  the  sacral  nerves  at  their  points  of  emergence  from  the  sacral  foramen.  In 
this  way  the  pelvic  nerve,  the  entire  pudendal  plexus,  and  the  posterior  cutaneous 
femoral  nerve  are  interrupted  and  a  complete  anesthesia  of  the  pelvic  organs 
and  lower  part  of  the  pelvic  peritoneum  is  obtained.  This  procedure  we  will  call 
parasacral  conduction  anesthesia,  deriving  the  idea  from  the  paravertebral  anesthesia 


320  LOCAL  ANESTHESIA 

of  Sellheim  and  Laewen  (page  314),  in  which  the  injection  was  also  made  into  the 
nerve  trunks  as  they  leave  the  spinal  canal. 

The  technique  for  parasacral  injections  is  as  follows :  The  two  points  of  injection  lie 
1,5  to  2  cm.  from  the  median  line  to  the  right  and  left  of  the  sacrococcygeal  articulation. 
Inspection  of  the  inner  surface  of  the  sacrum  shows  that  in  the  low^er  part,  between 
the  second  and  fifth  sacral  foramen,  there  is  very  little  curvature  to  the  bone,  which 
makes  it  possible  to  push  the  needle  forward  in  a  straight  line  along  the  inner  surface 
from  the  point  mentioned  to  the  second  sacra  foramen,  without  losing  the  contact  ' 
between  the  point  of  the  needle  and  the  bone.  Above  the  second  sacral  foramen  the 
point  of  the  needle  must  necessarily  strike  the  bone  and,  therefore,  cannot  be  inserted 
further.  In  the  adult  this  point  is  6  to  7  cm.  distant  from  the  point  of  entrance,  not 
taking  into  consideration  the  soft  structures. 


Fig.   144. — Position  of  the  needle  for  parasacral  conduction  anesthesia, 


The  patient  is  now  placed  in  the  lithotomy  position  and  the  needle  inserted  in  a 
direction  parallel  with  the  inner  surface  of  the  lower  half  of  the  sacrum;  with  the  point 
of  the  needle  the  edge  of  the  sacrum  is  sought  for.  Feeling  the  way  past  the  edge  of 
the  sacrum  the  needle  is  pushed  along  the  inner  surface  of  this  bone  parallel  to  its 
median  plane  until  it  strikes  the  bone  at  the  depth  mentioned.  The  entire  distance 
from  the  second  to  the  fifth  sacral  foramen  is  injected  with  20  c.c.  of  a  1  per  cent, 
novocain-suprarenin  solution.    No  injection  should  be  made  until  the  contact  with 


GEMTO-rRIXAh'Y   AM)   h'/'JCTAL  OI'I'JhWTIONS  321 

the  bone  is  felt.  The  needle  is  now  drawn  back  to  the  edge  of  the  sacruin  and  is  (hVccted 
at  a  small  angle  toward  the  innominate  line,  always  pushing  it  parallel  to  the  median 
plane.  In  this  direction  the  needle  penetrates  deeper  than  before,  until  it  again 
strikes  the  bone  above  the  first  sacral  foramen  at  a  distance  of  9  to  10  cm.  from 
the  point  of  cMitrance,  the  soft  parts  not  taken  into  consideration;  at  this  point  20  c.c. 
of  1  per  cent,  novocain-suprarenin  solution  is  injected.  The  final  injection  of  5  c.c. 
of  the  solution  is  made  between  the  rectum  and  the  coccyx  from  the  same  point  of 
entrance.  The  same  injection  is  made  on  the  opposite  side;  altogether  100  c.c.  of 
the  solution  are  required.  Fig.  144  shows  the  method  of  guiding  the  needle  as  has  been 
described.  The  needle  must  be  12  cm.  long  (No.  7,  page  174).  The  author  makes  this 
injection  without  the  aid  of  a  guiding  finger  in  the  rectum,  as  the  empty  bowel  is 
not  easily  injured  and  evades  the  needle.  If  the  operator  is  doubtful  on  this  point, 
then  the  position  of  the  needle  should  be  controlled  by  the  finger,  especially  in  making 
the  injection  to  the  first  sacral  nerve.  \\e  have  used  this  method  in  prostatectomies, 
in  operations  for  complete  prolapse  of  the  uterus,  both  with  and  without  artificial 
fixation  of  the  uterus,  in  extirpation  and  resection  of  the  rectum  for  carcinoma,  the 
rectum  being  painlessly  dissected  as  far  as  the  flexure. 

The  anesthesia  extends  higher  up  than  Laewen's  sacral  anesthesia,  and  aftects  the 
same  segments.  In  consequence  of  the  blocking  of  the  posterior  cutaneous  femoral 
nerve,  the  skin  of  the  posterior  surface  of  the  thigh  always  becomes  insensitive 
as  far  as  the  popliteal  space.  The  sphincter  ani  is  necessarily  paralyzed.  The  ureth- 
ral prostate  and  bladder  are  both  totally  insensitive.  Anesthesia  of  the  parietal 
peritoneum  does  not  extend  high  enough  for  an  extirpation  of  the  uterus,  for,  as  is 
well  known,  a  high  lumbar  anesthesia  is  necessary  for  this  purpose.  That  part  of  the 
peritoneum  supplied  by  the  sacral  plexus  alone  is  confined  to  the  floor  of  the  pelvis. 
Parasacral  anesthesia  is  a  most  reliable  form  of  anesthesia;  more  so  than  sacral  and 
without  secondary  effects.  This  reliability  is  attributed  to  the  fact  that  the  course 
taken  by  the  needle  is  determined  by  its  point  of  contact  with  the  bone. 


KIDNEY    OPERATIONS. 

Laewen  describes  a  pyelotomy  for  kidney-stone  which  was  successfully  performed 
under  local  anesthesia.  From  each  of  4  points  about  4  cm.  from  the  median  line  he 
made  paravertebral  injections  into  the  twelfth  intercostal  and  the  first  to  the  third 
lumbar  nerves,  using  10  c.c.  of  1  per  cent,  novocain-suprarenin  solution  and  circum- 
injected  the  field  of  operation  with  a  0.5  per  cent,  novocain-suprarenin  solution. 
The  luxation  of  the  kidney  was  the  only  part  of  the  operation  not  entirely  painless. 
For  kidney  operations  Kappis  recommends  the  simple  paravertebral  conduction 
21 


322 


LOCAL  ANESTHESIA 


anesthesia  without  the  concomitant  circuminjection.  For  this  purpose  the  eighth  i 
dorsal  to  first  kimbar  nerves  must  be  blocked;  for  operations  on  the  ureter,  the  second 
and  third  lumbar  nerves  must  also  be  blocked.  Kappis  states  that  since  the  develop- 
ment of  this  method  almost  all  kidney  operations  are  performed  under  local  anesthesia  i 
at  the  Kiel  clinic.  (Concerning  the  technique  of  the  paravertebral  injections  see  page  l 
279.)  Encouraged  by  this  statement,  the  author  used  Kappis'  technique  and  removed  ] 
successfully  a  large  hypernephroma.  The  patient  experienced  no  pain  during  this  j 
tedious  operation,  except  on  ligating  the  pedicle,  whereupon  several  whiffs  of  ether  1 


Figs.   145  and  146. — Technique  of  anesthesia  for  kidney  operations.     The  continuous  line  indicates 
the  extent  of  anesthesia. 


were  administered.  Three  nephrotomies  were  performed  in  the  following  manner 
(Figs.  145  and  146) :  In  each  of  the  cases  it  was  possible  to  determine  the  exact  extent 
of  the  anesthesia.  The  eighth  to  twelfth  dorsal  nerves  were  each  blocked  with  5  c.c, 
of  1  per  cent,  novocain-suprarenin  solution.  The  points  of  entrance  were  placed  in 
a  line  continuous  with  the  outer  edge  of  the  quadratus  lumborum  muscle.  Another 
point  was  marked  on  the  outer  edge  of  the  quadratus  muscle  at  the  crest  of  the  ilium. 
From  this  point  and  the  point  marked  for  the  twelfth  dorsal,  a  strip  of  tissue  extend- 
ing to  the  kidney  fat  was  infiltrated  thoroughly  with  about  75  c.c.  of  0.5  per  cent, 
novocain-suprarenin  solution  according  to  Fig.  29  (page  189).     No  further  injections 


GENirO-URINARY  AND  RECTAL  OI'K h'ATlOXS  323 

or  circuminjectioiis  were  necessary,  as  the  anesthesia  of  the  skin  was  extensive,  as 
shown  in  Figs.  145  and  14G.  The  operations  were  absolutely  painless,  were  performed 
ui)on  lean  persons,  and  the  kidney  was  easily  accessible.  The  luxation  of  the  kidney 
was  painless.  There  is,  therefore,  every  reason  to  believe  that  local  anesthesia  will 
soon  be  used  for  kidney  surgery. 


ANESTHESIA    OF    THE    MUCOUS    MEMBRANE    OF    THE    BLADDER   AND 
URETHRA. 

The  application  of  a  concentrated  solution  of  cocain  to  so  large  an  absorbing 
surface  as  the  bladder  and  the  male  urethra  is,  as  is  well  known,  dangerous  to  life. 
Numerous  patients  have  died  from  the  eflect  of  this  unreliable  method  of  cocain 
application.  Sudden  death  has  resulted  from  an  injection  into  the  urethra  of  5  c.c. 
of  a  1  per  cent,  cocain  solution  (Czerny).  The  secondary  toxic  effects  of  the  drug 
administered  in  this  manner  are  due  to  the  concentration  of  the  solution  and  not  to 
the  quantity  used.  Weak  cocain  solutions  (0.1  to  0.2  per  cent,  in  the  bladder,  0.5 
per  cent,  in  the  urethra)  with  the  addition  of  suprarenin  are  absolutely  safe  and 
produce  the  same  degree  of  anesthesia  as  concentrated  solutions,  if  kept  in  contact 
with  the  mucous  membrane  a  sufficient  length  of  time. 

Of  the  newer  remedies,  a  combination  of  alypin  and  suprarenin  is  the  best  substi- 
tute for  cocain.  The  application  of  a  concentrated  solution  of  this  remedy  is  per- 
missible, if  used  with  caution.  Garrasch  has  twice  experienced  severe  poisoning  (see 
page  120)  following  injections  of  5  c.c.  of  2  per  cent,  and  5  per  cent,  solutions  of 
alypin  into  the  urethra. 

In  order  to  render  the  mucous  membrane  of  the  bladder  insensitive  to  the  touch 
of  instruments  and  for  superficial  operations  the  bladder  should  be  filled  with  a 
0.5  per  cent,  solution  of  alypin  and  suprarenin,  and  allowed  to  remain  from  fifteen 
to  thirty  minutes.  If  the  mucous  membrane  of  the  bladder  is  not  sufficiently 
cleansed  before  the  solution  is  injected,  if  filled  with  blood,  or  if  the  mucous  mem- 
brane is  incrusted  or  covered  with  adherent  mucous,  it  will  be  impossible  to  bring 
the  solution  sufficiently  in  contact  with  the  mucous  membrane  to  obtain  anesthesia. 

In  intravesicular  manipulations,  made  through  the  urethra,  it  is  more  important 
to  anesthetize  the  more  sensitive  posterior  part  of  the  urethra  than  the  mucous 
membrane  of  the  bladder.  In  the  male  urethra  the  mucous  membrane,  when  pene- 
trable, is  made  insensitive  in  the  following  manner:  A  thin  Nelaton  catheter  is 
introduced  into  the  bladder  and  drawn  back  until  the  fluid  ceases  to  run;  5  c.c.  of 
a  1  per  cent,  alypin-suprarenin  solution  (for  the  proportion  see  page  180)  is  injected. 
At  the  same  time  the  catheter  is  gradually  withdrawn,  the  fluid  thus  being  prevented 


324 


LOCAL  ANESTHESIA 


from  escaping,  and  the  penis  is  tied  off  with  a  tape.  The  sohition  should  remain  in 
the  urethra  at  least  ten  minutes  or  a  quarter  of  an  hour.  This  is  absolutely  necessary, 
the  intensity  and  duration  of  the  local  anesthesia  depending  upon  the  length  of  time 
the  solution  remains  in  contact  with  the  parts. 

If  the  urethra  is  not  passable,  an  anterior  injection  is  made  and  the  penis  ligated. 
In  strictures  it  is  necessary  to  repeat  the  injection  when  the  stricture  has  become 
passable.  This  procedure  makes  catheterization  and  dilatation  of  strictures  entirely 
painless.  In  order  to  render  the  mucous  membrane  of  the  female  urethra  insensitive, 
all  parts  of  the  membrane,  from  the  external  orifice  to  the  neck  of  the  bladder,  must 
be  swabbed  with  a  2  per  cent  alypin-suprarenin  solution,  and  the  applications 
repeated  for  several  minutes.  The  anesthesia  thus  produced  will  not  be  sufficient 
for  extreme  dilatation  of  the  urethra  which  is  sometimes  necessary.  Complete 
anesthesia  can  be  obtained  for  this  manipulation  by  circuminjection  of  the  urethra 
with  a  0.5  per  cent,  novocain-suprarenin  solution. 


O 


Fig.   1 17. — Injoction  for  suprapubic  cystotomy. 


Suprapubic  Cystotomy. — Suprapubic  cystotomy  for  stone  in  the  bladder  can  be 
performed  almost  entirely  under  local  anesthesia.  After  thoroughly  washing  the 
bladder,  it  is  filled  with  a  0.5  per  cent,  alypin-suprarenin  solution.  Two  points  of 
entrance  are  marked  (Fig.  147),  and  the  injection  is  made  by  introducing  a  long  needle 
at  point  1,  close  over  the  symphysis,  and  directing  it  through  the  aponeurosis,  in 
various  directions,  deep  into  the  prevesical  space  and  infiltrating  this  freely  with  40 
to  50  c.c.  of  a  0.5  per  cent,  novocain-suprarenin  solution.  The  abdominal  layers  in 
the  line  of  the  incision  are  then  made  anesthetic  by  injecting  from  both  points,  as 
described  on  page  301.  For  this  injection  20  c.c.  more  of  the  same  solution  are  neces- 
sary.   In  most  cases  the  wall  of  the  bladder  which  is  exposed  above  the  symphysis  is 


GEXITO-rix'IXAh'Y   AM)   RECTAL  OPERATIONS  325 

not  sensitive  to  pain.  In  a  few  cases  it  is  necessary  to  infiltrate  the  line  of  incision  in 
the  bladder  more  thoroughly  before  cutting,  probably  on  account  of  the  insufficient 
infiltration  of  the  prevesical  space. 


OPERATIONS    ON    THE    SCROTUM    AND    TESTICLES. 

The  skin  of  the  scrotum  and  the  tunica  vaginalis  communis  receives  its  innervation 
for  the  most  part  from  the  perineum,  from  the  subcutaneous  terminal  branches  of 
the  pudic  nerve  and  the  posterior  cutaneous  femoral.  Above  it  is  also  supplied  by 
branches  of  the  ilio-inguinal  and  the  external  spermatic  as  they  emerge  from  the 
inguinal  canal.     The  two  last  named  nerves  alone  supply  the  spermatic  cord,  the 


;iiinjection  of  penis  and  scrotum  for  operat 


testicles  and  the  tunica  vaginalis  propria.  For  the  complete  anesthesia  of  these  parts 
the  following  injection  is  necessary.  One  point  of  entrance  is  marked  on  each  side 
where  the  spermatic  cord  crosses  the  pubic  bone,  another  is  marked  laterally  where 
the  scrotal  skin  emerges  with  the  skin  of  the  thigh  (Fig.  148). 

The  next  step  is  to  produce  anesthesia  in  the  spermatic  cord  with  its  nerves,    lieclus 
lifts  the  spermatic  cord  with  two  fingers  of  the  left  hand  and  injects  the  anesthetic 


326 


LOCAL  ANESTHESIA 


into  the  cord  (Fig.  149).    It  is  not  always  possible  to  lift  up  the  cord  as,  for  example, 
in  a  large  hydrocele  that  extends  high  up,  for  which  reason  the  following  method  is 


Fig.  149. — Injection  into  the  spermatic  cord.     (After  Reclus.) 


Fig.   150. — Fan-shape  injection  upon  the  puljic  bone  for  hydrocele. 

preferable:  A  needle  is  inserted  from  point  1  toward  the  underlying  pubic  bone  until 
the  bone  is  felt  with  the  point  of  the  needle,  and  a  bilateral  fan-shaped  injection 
of  5  c.c.  of  0.5  per  cent,  novocain-suprarenin  solution  is  made  in  three  directions, 


GEN  I  TO-URINARY  AND  RECTAL  OPERATIONS 


327 


perpendicular  and  lateral  to  the  symphysis.  In  Fig.  150  the  needles  indicate  the 
two  last  mentioned  directions.  In  this  way  the  spermatic  cord  cannot  be  missed. 
Finally,  an  extra  injection  of  10  c.c.  of  0.5  per  cent.  novocaiii-sui)rarenin  solution  is 


Fig.   151. — Injection  in  tho  inguinal  canal  for  hydrocele. 


Fig.    1.52. — Circumiiijection  of  tlie 


of  the  scrotum. 


328  LOCAL  ANESTHESIA 

injected  into  the  inguinal  canal  (Fig.  151),  in  this  manner  obtaining  a  reliable 
blocking  of  the  nerves  accompanying  the  spermatic  cord.  In  bilateral  operations 
this  manipulation  must  naturally  be  carried  out  on  both  sides.  These  injections 
must  be  followed  by  a  subcutaneous  circuminjection  of  the  entire  scrotum,  whether 
the  condition  be  uni-  or  bilateral,  made  in  a  line  connecting  the  four  points  of 
entrance  (Fig.  148).  Fig.  152  demonstrates  the  position  of  the  needle  for  the 
subcutaneous  injection  from  point  4  toward  the  perineum.  In  fat  persons  it  is 
necessary  to  infiltrate  freely  the  circular  line  of  injection  in  layers,  in  order  to 
block  with  certainty  the  posterior  scrotal  nerve.  Not  infrequently,  50  c.c.  or 
more  of  0.5  per  cent,  novocain-suprarenin  solution  is  necessary  for  the  circumin- 
jection. This  procedure  is  suitable  for  all  operations  on  the  scrotum  and  testicle 
and  is  also  specially  suitable  for  the  radical  operation  for  hydrocele  and  for 
ablation  of  the  testes. 

If  these  operations  are  performed  through  Kocher's  inguinal  incision  the  spermatic 
cord  is  immediately  exposed  at  the  beginning  of  the  operation.  If,  after  exposing 
the  tunica  and  the  testicle,  it  is  found  that  the  injection  of  the  cord  has  not  been 
successful,  an  accident  which  is  very  apt  to  happen  to  a  surgeon  who  is  not 
at  once  familiar  with  these  methods,  it  will  be  necessary  to  inject  a  few  drops  of 
a  2  per  cent,  novocain-suprarenin  solution  into  the  spermatic  cord  in  order  to 
obtain  the  desired  anesthesia. 


OPERATIONS    ON    THE    PENIS. 

For  a  simple  dorsal  incision  of  the  prepuce  in  phimosis  it  is  only  necessary  to  infil- 
trate the  line  of  incision  by  an  injection  between  the  skin  and  mucous  membrane. 
A  very  fine  needle  is  inserted  into  the  edge  of  the  foreskin  (Fig.  153)  and  passed 
between  the  skin  and  mucous  membrane  upward  over  the  coronary  sulcus,  injecting 
along  this  line  1  to  2  c.c.  of  1  per  cent,  novocain-suprarenin  solution.  Occasionally 
it  is  easier  to  make  the  injection  from  a  point  on  the  dorsum  of  the  penis.  The  needle 
in  this  case  is  pushed  forward  subcutaneously  to  the  edge  of  the  prepuce. 

Anesthesia  of  the  entire  prepuce  for  phimosis  is  produced  as  follows:  The  foreskin 
is  drawn  tensely  over  the  glans  and  is  held  in  this  position  by  tying  with  tape. 
The  anesthetic  is  injected  subcutaneously  and  circularly  into  the  coronary  sulcus, 
and  the  tape  is  not  removed  until  after  the  anesthesia  has  become  complete.  In 
cases  of  paraphimosis  it  is  necessary  to  make  a  circular  injection  into  the  coronary 
sulcus,  and  one  above  the  constricting  band.  Injections  of  suprarenin  solution 
into  the  peripheral  parts  of  the  penis  must  be  made  with  caution  as  the  arteries 
supplying  the  prepuce  are  end   arteries.      If  the   novocain-suprarenin    solution   is 


GENI TO-URINARY  AND  RECTAL  OPERATIONS 


329 


injected  too  freely,  tlu<  ell'ect  oi'  the  siii)rareniii  may  last  too  Ioiik,  and  a  prepuce 
treated  in  this  manner  will  he  in  a  similar  condition  to  a  i)e(licled  skin  flap  (see 
page  145).    As  a  result  of  the  contraction  of  all  the  arteries  the  tissues  are  unable 


Fig.   153. — Injection  for  the  dorsal 


Fig.    1."j4.— Anesthesia  of  the  cnt 


to  throw  otl'  the  injected  substances,  or  do  it  too  slowly  and  in  this  way  cause  damage 
to  the  tissues.  Damage  of  this  character  has  been  reported,  but  may  be  avoided  by 
never  injecting  more  than  1  or  1.5  cm.  of  1  per  cent,  novocain-suprarenin  solution 


330  LOCAL  ANESTHESIA 

into  a  penis.  It  is  therefore  advisable  that  the  circular,  peripheral  injection  into  the 
penis  be  avoided  and  that  the  entire  penis  be  made  insensitive  by  injections  at  its 
base,  even  in  operations  for  phimosis.  If  a  circular  subcutaneous  injection  of  an 
anesthetic  is  made  around  the  shaft  of  the  penis,  as  described  by  Krogius,  the  glans 
and  mucous  membrane  of  the  foreskin  are  often  not  made  insensitive,  giving  rise 
to  serious  complaint  in  operations  for  phimosis.  This  is  not  the  case  if  the  injection 
is  made  close  to  the  symphysis  in  the  following  manner  (Fig.  154): 

Anesthesia  of  the  Entire  Penis.^ — Two  points  of  injection  are  made,  one  to  the 
right  and  one  to  the  left  of  the  base  of  the  penis,  at  a  point  where  the  spermatic  cord 
crosses  the  horizontal  ramus  of  the  pubes.  From  these  two  points,  with  the  penis 
drawn  out  and  held  in  this  position,  a  0.5  per  cent,  novocain-suprarenin  solution 
is  injected.  The  needle  is  then  passed  as  deep  as  the  corpora  cavernosa,  circum- 
injecting  them  at  the  point  where  they  emerge  from  the  angle  of  the  symphysis  and 
unite  with  the  shaft  of  the  penis.  From  below  the  needle  penetrates  the  scrotum, 
above  it  reaches  the  suspensory  ligament  of  the  penis.  In  fat  persons  long  needles 
are  necessary.  A  second  injection  just  under  the  skin  is  then  made  corresponding 
with  the  dark  line  in  Fig.  154.  In  an  adult  with  a  moderate  amount  of  fat  about 
40  c.c.  of  0.5  per  cent,  solution  are  required,  a  proportionately  smaller  quantity  being 
used  in  children.  The  entire  penis,  skin,  prepuce,  glans,  the  pendulous  portion  of  the 
urethra,  and  the  corpora  cavernosa,  distal  to  the  pubes,  are  rendered  insensitive.  This 
method  is  suitable  for  all  operations  on  the  parts  named — for  example,  in  amputa- 
tions of  the  penis,  plastic  operations  on  the  urethra  (hypospadia  glandis),  urethral 
fistulse  and,  as  has  been  stated,  for  phimosis  and  paraphimosis. 

For  extirpation  of  inguinal  glands  in  connection  with  amputation  of  the  penis,  see 
Chapter  XYI. 


OPERATIONS  ON  THE  POSTERIOR  PART  OF  THE  URETHRA. 
EXTERNAL  URETHROTOMY. 

For  years  external  urethrotomy  for  strictures  and  recent  injuries  have  been  per- 
formed almost  without  exception  under  local  anesthesia  in  the  following  manner:  In 
the  median  line  in  front  of  the  anus  one  point  is  marked  (Fig.  155)  and  an  imaginary 
horizontal  plane  is  drawn  through  this  point.  In  the  diagram  this  is  shown  by  a 
horizontal  line.  This  plane  separates  the  anus  and  the  rectum  on  one  side  from  the 
bulbus  urethrae  and  the  prostate  on  the  other.  Laterally  it  passes  through  the  ischio- 
rectal fossa  on  each  side  and  meets  the  ascending  ramus  of  the  ischium  in  front  of  the 
tuberosities.  This  plane  must  be  infiltrated  with  a  0.5  per  cent,  no^-ocain-suprarenin 
solution.    For  this  purpose  the  left  index  finger  is  inserted  into  the  anus,  and  a  needle 


e 


GEMTO-rBIXAliY  AXD  RECTAL  Ol'KHATIONS 


331 


S  to  10  cm.  long  is  inserted  into  the  median  plane  between  the  bulbus  urethne  and  the 
anus,  and  a  continuous  injection  is  made,  as  high  up  as  possible,  between  the  rectum 
and  the  prostate.  In  the  next  two  injections  the  needle  is  directed  further  to  the  right 
and  left,  reaching  the  lateral  lobes  of  the  prostate  and  rectum.  In  the  next  two  injec- 
tions it  is  passed  within  the  transverse  plane  and  always  from  the  same  point  of 
entrance  still  more  laterally,  penetrating  deeply  into  the  ischiorectal  fossa.  In  the  last 
two  injections  the  needle  is  directed  almost  transversely  to  the  right  and  left,  striking 
the  ascending  ramus  of  the  ischium.    The  final  subcutaneous  injection  is  not  made 


in  the  horizontal  plane  but  as  shown  in  Fig.  155  in  the  direction  between  the  scrotum 
and  the  thigh,  in  order  to  block  those  nerves  of  the  skin  which  might  extend  from 
the  side  to  the  perineum  and  the  scrotum;  about  75  c.c.  of  0.5  per  cent,  solution  is 
necessary.    The  course  of  the  needle  in  deep  injections  is  reproduced  in  Fig.  156. 

All  the  branches  of  the  pudic  nerve  and  the  posterior  cutaneous  femoral  which 
supply  the  prostate,  urethra  and  the  external  genitalia  are  blocked  with  certainty 
(see  Fig.  140  (page  316).  Franke  and  Posner  have  observed  that  the  infiltration 
behind  the  prostate  is  an  important  factor  in  the  blocking  of  the  pelvic  ne^^•e.  The 
perineum,  the  posterior  surface  of  the  scrotum,  the  entire  urethra  from  the  neck  of 


332 


LOCAL  ANESTHESIA 


the  bladder  to  the  external  orifice  and  the  prostate  are  rendered  insensitive.  The 
patient  does  not  feel  the  entrance  of  the  catheter  and  all  operations  performed  in 
this  region  are  painless.  The  perineal  dissection  of  the  prostate  is  usually  not  alto- 
gether painless,  as  violent  pulling  on  the  organs  cannot  be  avoided.  The  method 
described  has  the  same  effect  and  is  more  reliable  than  Laewen's  sacral  anesthesia, 


Fig.   156. — Transverse  infiltration  of  perineum;  position  of  needles. 


and  is  preferable,  as  the  anemia  of  the  field  of  operation  produced  by  the  supra  renin 
is  of^great  value.  Only  when  the  injections  cannot  be  made  behind  the  urethra  and 
prostate,  as  in  urinary  infiltration  and  in  abscesses,  is  sacral  anesthesia  to  be  pre- 
ferred to  direct  anesthesia  of  the  field  of  operation.  Sometimes  the  method  described 
is  combined  with  anesthesia  of  the  entire  scrotum   (page  325)  for  amputation  of 


GENirO-URINAh'Y   AM)  RECTAL   Ol'EUATIONS  333 

the  i)enis,  for  the  median  spHttiiit;-  of  the  serotuin,  and  for  sewiii<;'  the  urethra    into 
the  ])erintnnn,  aeeording  to  the  method  of  Thierseh. 

Prostatectomy. — ^Parasacral  conduction  anesthesia  (paj^c  ;)2())  is  tlie  most  suitable 
for  i)erforming  the  perineal  or  Wilms  prostatectomy.  Suprapubic  prostatectomy  is 
])erformed  in  the  following  manner:  The  patient  usually  receives  1  eg.  of  morphin 
preceding  the  anesthesia,  which  is  the  same  as  for  "sectio  alta"  (page  324).  The 
shelling  out  of  the  prostate  is  done  under  ether  or  ethyl  chlorid  anesthesia.  After 
opening  the  bladder  Payr  circuminjects  the  prostate  through  the  bladder.  The  cir- 
cuminjection  is,  however,  more  satisfactory  if  it  is  made  from  the  perineum,  as  advised 
by  Colmers.  It  is  a  mistake  to  prepare  the  patient  with  heavy  doses  of  veronal, 
pantopon,  or  scopalomin,  as  recommended  by  Colmers.  In  aged  patients  these  opiates 
must  be  used  very  cautiously,  and  are  not  at  all  necessary  in  prostatectomies.  In 
abdominal  operations,  where  abdominal  sensations  are  to  be  avoided,  the  previous 
preparation  of  the  patient  with  opiates  is  permissible. 


VAGINAL   OPERATIONS. 

While  the  older  reports  of  Reclus  and  Schleich  regarding  the  use  of  local  anesthesia 
for  vaginal  operations  did  not  seem  to  find  favor  among  gjaiecologists,  nevertheless 
they  have  recently  begun  to  use  local  anesthesia  in  this  field  as  well  as  in  general 
surgery.  Among  the  gynecologists  Freund  (1904)  was  the  first  to  interest  himself 
in  local  anesthesia.  In  colporrhaphies  he  recommended  subcutaneous  and  sub- 
mucous injections  of  1  c.c.  of  1  per  cent,  eucain  solution  with  the  addition  of  supra- 
renin  to  be  introduced  at  each  point  for  both  anterior  and  posterior  operations. 
For  plastic  perineal  operations  and  colporrhaphies  Fisch  and  Wagner  have  also 
found  local  anesthesia  satisfactory.  Henrich,  a  pupil  of  Freund,  also  Fisch,  Wernitz, 
and  Kraatz  have  used  local  anesthesia  for  operations  on  the  cervix,  for  dilatation 
of  the  cervix  and  for  curettements.  Wernitz  used  unsuitable  remedies  (1  to  2  per 
cent,  cocain  solution)  and,  as  was  to  be  expected,  experienced  cocain  poisoning. 
Fisch  brought  the  modern  novocain-suprarenin  solution  to  the  attention  of  gynecolo- 
gists. Ruge  reported  two  total  vaginal  extirpations  under  local  anesthesia.  Reclus 
had  described  such  an  operation  sometime  before,  but  his  case  was  one  of  prolapse 
of  the  uterus.  Reference  has  already  been  made  to  anesthesia  of  the  pudic  nerve 
(page  318).  Sellheim  very  appropriately  remarks  that  conduction  anesthesia  of  the 
pudic  nerves  can  be  much  more  reliably  obtained  by  injecting  large  quantities  of 
the  solution  to  various  depths  and  in  various  directions,  in  the  neighborhood  of  the 
nerves  as  they  emerge  from  the  ischiorectal  fossa.  If  we  further  add  that  Mathes 
and  Schmidt  are  warmly  in  favor  of  repairing  perineal  tears  under  local  anesthesia 


334 


LOCAL  ANESTHESIA 


and  that  Thaler  has  successfully  emptied  the  gravid  uterus  under  local  anesthesia, 
we  will  have  about  exhausted  the  literature  upon  the  subject.     It  cannot  be  said  - 
that  much  has  been  done  in  this  field,  if  these  reports  are  to  be  compared  with  the 
progress  that  has  been  made  in  the  use  of  local  anesthesia  in  general  surgery. 

Operations  on  the  Labia. — Large  and  small  cysts  and  solid  tumors  of  all  kinds,  both 
on  the  labia  majora  and  minora,  should  always  be  removed  under  local  anesthesia, 
according  to  the  general  rules  given  in  Chapter  X.  For  the  removal  of  the  tumor 
shown  in  Figs.  157  and  158  there  were  three  points  of  entrance  marked.  Point  1 
on  the  perineum,  point  2  laterally,  and  point  3,  which  is  not  visible  in  the  diagram, 


Figs.   157  and  158. — Extirpation  of  a  tumor  of  the  labia  maj< 


is  placed  above  the  tumor.  From  these  three  points  40  c.c.  of  0.5  per  cent,  novocain- 
suprarenin  solution  were  injected,  part  under  the  tumor,  and  a  part  used  for  the 
subcutaneous  circuminjection,  made  in  the  direction  of  the  dotted  line.  In  case  of 
a  malignant  tumor  it  is  more  advisable  to  anesthetize  the  entire  vulvar  orifice, 
which  method  will  be  described  later. 

Repairing  Recent  Perineal  Tears. — For  repairing  recent  perineal  tears  it  is  advis- 
able to  inject  under  and  around  the  entire  wound  with  a  0.5  per  cent,  novocain- 
suprarenin  solution.  According  to  ]\Iathes  the  points  of  entrance  are  placed  in  the 
mucous  membrane  of  the  vagina,  which  is  already  insensitive,  or  the  injection  is  made 
according  to  Schmidt  from  the  wound  surface  into  the  rectovaginal  septum.    Schmidt 


GENITO-UNIXARV  AXD  RECTAL   OI'Eh'ATlOXS  3.>") 

estimates  the  ainoimt  necessary  for  this  operation  to  he  (iO  to  70  c.e.  of  ().">  per 
cent,  novocain-siiprarenin  sohition. 

Anesthesia  of  the  Vulvar  Orifice. — The  injection  technique  corresponds  exactly 
witli  that  (k'serihetl  on  page  '.VM  for  external  urethrotomy  in  the  male.  Accordingly, 
one  point  of  injection  is  marked  in  the  median  line  in  front  of  the  anus;  an  imaginary 
Hue  is  drawn  in  a  horizontal  plane,  which  separates  the  vagina  from  the  rectum  and 
laterally  meets  the  tuberosities  of  the  ischium.  This  plane  should  be  infiltrated  with 
0.5  per  cent,  novocain-suprarenin  solution.  A  needle  8  to  10  cm.  long  is  inserted 
(Xo.  5  or  (),  page  174)  and  passed  in  the  median  line  between  vagina  and  rectum 
ahnost  to  the  peritoneum.  It  is  then  drawai  back  as  far  as  the  subcutaneous  connective 
tissue  and  directed  a  little  more  to  the  right  and  the  left,  always  remaining  in  the 
horizontal  plane  mentioned,  and  again  deeply  inserted  between  rectum  and  vagina. 
In  guiding  the  needle  in  the  third  direction,  the  point  reaches  still  farther  to  the  right 
and  left,  deep  into  the  ischiorectal  fossa,  and  with  the  fourth  injection  the  point  of 
the  needle  reaches  the  tuberosities  of  the  ischium.  The  principle  of  these  injections 
is  shown  in  Fig.  156. 

The  first  injection  is  made  with  a  guiding  finger  in  the  vagina  or  rectum.  Care 
must  be  taken  not  to  infiltrate  the  plane  immediately  under  the  mucous  membrane 
of  the  vagina,  but  as  close  as  possible  to  the  wall  of  the  rectum.  During  the  insertion 
of  the  needle  constant  injection  should  be  made.  A  final  subcutaneous  injection 
will  be  necessary  just  as  in  the  male,  not  in  the  horizontal  plane  but  in  a  direction 
between  the  thigh  and  labia  majora.  Altogether  75  to  100  c.c.  of  0.5  per  cent,  novo- 
cain-suprarenin solution  will  be  necessary.  The  injection  blocks  those  branches  of 
the  pudic  nerve  and  of  the  posterior  femoral  cutaneous  (see  Fig.  141,  page  319)  which 
pass  to  the  front.  Therefore,  the  parts  made  insensitive  are  the  perineum,  the  vulvar 
orifice,  the  posterior  part  of  the  labia  majora,  the  labia  minora,  the  urethra  and  the 
clitoris.  This  method  is  suitable  for  plastic  operations  on  the  perineum,  operations 
on  the  labia  minora,  about  the  meatus  of  the  urethra  and  for  rectovaginal  fistula. 

Anesthesia  of  the  Vulvar  Orifice,  Including  the  Labia  Majora  (Fig.  159).— In  this 
case  the  horizontal  infiltration  of  the  perineum  just  described  should  be  used.  Two 
extra  points  of  injection  are  marked  beneath  and  inward  from  the  outer  inguinal 
ring.  From  these  points  the  subcutaneous  tissue  around  the  pubic  eminence  and  at 
the  side  of  the  labia  majora  is  freely  infiltrated  toward  the  injection  already  made 
in  the  perineum  with  a  0.5  per  cent,  novocain-suprarenin  solution.  By  this  means 
the  nerve  branches  w^hich  come  from  the  side  and  above  are  blocked,  especially 
those  coming  from  the  inguinal  canal  and  spreading  out  into  the  labia  majora. 
Altogether  125  to  150  c.c.  of  0.5  per  cent,  novocain-suprarenin  solution  will  be 
necessary.  In  operations  for  carcinoma  of  the  \u\xa  with  removal  of  glands  this 
method  should  be  used  (see  Chapter  XVI). 


336 


LOCAL  ANESTHESIA 


Operations  for  Prolapse. — In  order  to  obtain  complete  anesthesia  in  operations 
for  prolapse,  vaginal  injections  will  be  found  to  be  indispensable.  The  transverse 
perineal  infiltration  is  unreliable  in  affecting  the  sensibility  of  the  posterior  pelvic 
peritoneum,  and  does  not  affect  the  bladder  at  all.  For  example,  in  a  case  of  anterior 
and  posterior  colporrhaphy  with  large  cystocele,  the  injection  of  0.5  per  cent,  novo- 
cain-suprarenin  solution  is  made  in  the  following  manner:     The  anterior  lip  of  the 


Fig.    159. — Anesthesia  of  the  introitus  vagiiue,  including  the  labia  majora. 


cervix  uteri  is  held  by  a  volsellum  and  the  prolapsed  part  is  drawn  forward.  A  needle 
from  8  to  10  cm.  long  is  inserted  close  over  the  portio  and  the  solution  (20  c.c.)  is 
injected  in  a  fan-shaped  manner  upward  betw^een  the  bladder  and  the  cervix  (Fig. 
160),  but  not  submucously.  From  a  point  close  beneath  the  opening  of  the  urethra 
injections  of  10  c.c.  each  are  made  to  the  right  and  left  under  the  mucous  membrane. 
This  last  injection  is  particularly  serviceable  in  producing  a  more  marked  anemia. 
The  portio  of  the  uterus  is  drawn  to  the  right,  and  15  c.c.  are  injected  into  the  left 
parametrium;  the  same  injection  is  made  into  the  right  parametrium,  the  neck  of 
the  uterus  being  drawn  to  the  left.  Then  a  volsellum  is  hooked  into  the  posterior 
lip  of  the  cervix  and  20  c.c.  are  injected  from  a  point  just  behind  the  portio  in  a 


GEN ITO-URI NARY  AND  RECTAL  OPERATIONS 


337 


fan-shaped  manner  between  the  vaginal  mucous  membrane  and  Douglas'  cul-de-sac. 
The  prolapsed  part  is  replaced,  after  which  the  previously  described  horizontal  peri- 
neal injection  is  made.  For  the  whole  injection  about  200  c.c.  of  a  0.5  novocain- 
suprarenin  solution  will  be  necessary.  The  operation  is  totally  painless,  even  when 
patients  have  received  no  opiate.  It  is  advisable,  h()we\er,  for  psychic  reasons  to 
give  a  little  morphin  or  morphium-scopolamin. 


II 


Fig.  160. — Anterior  colporrhaphy. 


This  method  has  been  used  for  a  sufficient  length  of  time  to  prove  its  advantages 
over  all  others.  It  is  more  reliable,  less  dangerous,  and  has  the  advantage  of  pro- 
ducing a  satisfactory  anemia  and  should  be  given  preference  over  other  methods  of 
anesthesia,  such  as  pudic  nerve  anesthesia,  sacral  and  lumbar  anesthesia.  Lumbar 
anesthesia  is  certainly  contra-indicated  for  the  previously  mentioned  operations. 

22 


338  LOCAL  ANESTHESIA 

For  posterior  colporrhaphy  alone,  the  horizontal  perineal  infiltration  together  with 
injections  into  the  posterior  vaginal  vault  are  sufficient.  For  anterior  colporrhaphy 
alone,  the  anterior  injections  are  sufficient  in  themselves,  provided  the  vaginal 
entrance  is  not  too  sensitive. 

Parasacral  anesthesia  is  particularly  suitable  for  prolapse  operations,  but  it  lacks 
the  advantage  of  the  anemia  obtained  from  the  suprarenin  in  the  injections  just 
described. 

OPERATIONS    ON    THE   UTERUS. 

Henrich,  Fisch,  and  Kraatz  infiltrate  the  portio  \aginalis  and  the  cervix  with  the 
anesthetic.  Kraatz's  method  is  to  insert  the  needle  into  four  points  placed  as  near  as 
possible  to  the  outer  border  of  the  portio,  directing  it  parallel  with  the  cervical  canal 
to  the  lowermost  part  of  the  body  of  the  uterus;  he  injects  5  c.c.  of  0.5  per  cent, 
novocain-suprarenin  solution  at  each  point,  using  altogether  20  c.c.  The  controlling 
index  finger  feels  the  injected  fluid  as  it  forms  a  swelling  above  the  vaginal  fornix.         • 

All  operations  confined  to  the  portio  and  cervix,  even  dilatation,  can  be  performed.  J 
It  will  be  noted  here  as  elsewhere  that  there  is  little  bleeding  from  the  arteries  | 
on  account  of  the  effect  of  the  suprarenin,  and  therefore  any  bleeding,  even  though  ' 
it  appears  slight,  must  be  stopped  by  suture.  ! 

Dilatation  of  the  cervix  is  painless,  but  curettement  is  more  or  less  painful  in  pro-  ■ 
portion  to  the  sensitiveness  of  the  patient  or  the  quantity  of  the  sedative  that  has 
previously  been  administered.  Severe  traction  on  the  uterus  which  is  transmitted  . 
to  the  pelvic  peritoneum  remains  more  or  less  painful.  It  is  therefore  essential  that  \ 
further  experiments  be  made  in  order  to  decide  whether  it  is  not  more  advisable  I 
to  render  the  entire  organ  as  well  as  the  pelvic  floor  insensitive  by  parametric  injec-  "? 
tions  in  all  cases  of  uterine  operations.  ;j 

With  the  exception  of  Wernitz  whose  injections  were  purposeless  and  insufficient,    J| 
Ruge  was  probably  the  first  to  make  parametric  injections.     He  describes  them  in 
the  following  manner:    A  needle  is  inserted  from  4  to  5  cm.  into  the  parametrium    jj 
to  the  right  and  left  of  the  uterus.    It  is  at  once  directed  slightly  to  the  side  in  order    | 
to  block  the  nerves  which  enter  the  parametrium,  as  far  as  possible  from  the  uterus,    | 
in  order  to  obtain  as  extensive  an  anesthesia  of  the  pelvic  floor  as  possible.    On  each    \\ 
side  10  c.c.  of  1  per  cent,  novocain-suprarenin  solution  are  injected.     In  the  same    ' 
manner  5  c.c.  of  the  solution  are  injected  2  to  3  cm.  deep  into  each  of  two  points  on    j 
the  anterior  and  posterior  vaginal  vault.     Altogether  about  40  c.c.  of  1  per  cent.    '■ 
novocain-suprarenin  solution  will  be  required.    This  emphatically  proves  the  progress 
made  b}'  local  anesthesia.     Wernitz  injects  2  to  4  cm.  of  1  to  2  per  cent,  cocain 
solution,  a  quantity  of  anesthetic  much  too  small  to  produce  an  efficient  anesthesia  in 


aENITO-URINARY  AND   RECTAL  Ol'ERATlONH  WW.) 

this  region  and  he  Jias  even  cx])eritMK'e(l  cocaiii  i)()is()iiiiii;-  with  this  small  amount. 
Huge  can  inject  a  ten  times  hirger  quantity  of  an  anesthetic,  whicli  is  just  as  eU'ectiNc 
without  secondary  complications,  and  it  is  even  possible  to  double  the  amount  of  1 
per  cent,  novocain-suprarenin  solution  without  bad  results.  It  may  be  possible 
in  this  manner  to  make  the  entire  pelvic  floor  with  the  uterus  and  its  surroundings 
insensitive;  this  occurred  in  two  of  Ruge's  cases.  iVbsence  of  ])ain  is  imperative  for 
all  uterine  extirpations  and  most  vaginal  laparotomies.  In  making  these  injections 
it  is  necessary  to  use  very  fine  needles  in  order  to  avoid  injury.  We  know  that  there 
is  no  damage  done  in  accidentally  penetrating  the  subclavian  or  carotid  artery  and 
the  same  is  probably  true  of  the  ureter  and  uterine  artery.  Furthermore,  the  general 
directions  (page  180)  should  be  followed,  namely,  to  first  insert  the  needle  without 
the  syringe  in  places  where  injury  might  be  done,  and  avoid  making  injections  in 
those  places  where  blood  flows  from  the  needle.  All  injections  must  be  made  while 
the  needle  is  in  motion.  If  the  patients  are  young  women  with  tense  vaginae,  some 
method  of  anesthetizing  this  part  for  uterine  operations  must  be  employed.  It  may 
be  possible  to  obtain  sufficient  anesthesia  of  the  vagina  by  making  superficial  appli- 
cation of  the  anesthetic  solutions  of  alypin  and  suprarenin.  The  perineal  injection 
described  above  certainly  makes  the  vagina  sufficiently  insensitive  for  any  amount 
of  distention. 

Thaler  performed  vaginal  hysterectomies  and  the  emptying  of  gravid  uteri  at  an 
early  stage  in  nine  women  with  complete  anesthesia  and  very  little  bleeding;  0.5 
novocain-suprarenin  solution  was  injected  in  the  following  manner:  After  emptying 
the  bladder  a  volsellum  was  hooked  into  the  anterior  lip  of  the  cervix  and  10  c.c.  of 
solution  were  injected  beneath  the  mucous  membrane  of  the  vaginal  vault  where  the 
transverse  anterior  colpotomy  incision  was  to  be  made.  The  needle  was  introduced 
superficially  (0.75  to  1  cm.  deep).  Injections  of  12  c.c.  of  the  solution  were  made  into 
the  parametrium  both  to  the  right  and  left  of  the  uterus  to  a  depth  of  1  to  1.5  cm. 
In  a  large  uterus,  after  splitting  the  anterior  cervix  to  the  internal  os,  an  additional 
injection  of  10  c.c.  of  the  solution  was  made  directly  into  the  wall  of  the  uterus  in 
order  to  increase  the  local  effect  of  the  suprarenin  upon  the  muscles  of  this  organ. 
It  was  not  necessary  to  prepare  the  patient  by  the  administration  of  an  opiate. 
The  way  has  been  paved,  and  in  a  few  years  we  will  i)robably  be  able  to  say  more 
in  favor  of  local  anesthesia  in  gynecology. 


OPERATIONS    IN    THE    ANAL    REGION. 

Local  anesthesia  for  operations  on  the  anus  is  worthy  of  more  consideration  than 
it  has  received   in   the    past,  for  such  operations  can  easily  be  performed  without 


340 


LOCAL  ANESTHESIA 


general  anesthesia.  Reclus  and  Schleich  (the  former  as  early  as  1889)  have  again 
and  again  called  attention  to  the  fact  that  the  anal  region  is  particularly  suitable 
for  performing  operations  under  local  anesthesia,  and  it  was  not  without  special 
reasons  that  Schleich  selected  an  anal  operation  for  demonstration  at  the  German 
Congress  of  Surgeons  in  1894.  To  one  who  is  unfamiliar  with  this  subject  there  is 
something  surprising  in  seeing  the  painlessness  of  a  forced  dilatation  of  the  anus  and 
the  excision  of  hemorrhoids  without  a  general  anesthetic.  It  is,  therefore,  all  the  more 
remarkable  that  anal  operations  are  still  being  performed  under  general  or  lumbar 
anesthesia. 


161. — Circuminjcction  of  anus  and  rectum. 


Dilatation  of  the  Anus ;  Operations  for  Hemorrhoids ;  Operations  for  Anal  Fistulae. 

—Before  beginning  operations  of  this  kind  it  must  be  remembered  that  the  bilateral 
blocking  of  the  trunk  of  the  pudic  nerve  will  not  be  sufficient  to  produce  anesthesia 
of  the  anus,  neither  will  the  filling  of  the  ischiorectal  fossa  with  a  0.5  per  cent, 
novocain-suprarenin  solution  be  sufficient;  even  though  the  latter  procedure  causes 
a  more  reliable  blocking  of  the  branches  of  the  pudic  and  posterior  femoral  cutaneous 


GENITO-UIUNARY  AND  RECTAL  OPERATIONS 


341 


nerves  which  supply  the  anus  tliau  is  jirochiced  by  the  uncertain  injection  of  the 
trunk  of  the  pudic  nerve. 

Tlie  further  innervation  of  the  rectum  and  anus  through  tlie  coccygeal  plexus  and 
pelvic  nerve  must  also  be  taken  into  consideration.  Laewen's  sacral  injection  pro- 
duces a  splendid  relaxation  of  the  sphincter  ani  and  anesthesia  of  the  anal  region. 
Unfortunately  it  is  not  reliable  and  a  better  method  is  in  circuminjecting  the  anus. 
In  some  operations  about  the  anus,  the  anemia  produced  by  the  suprarenin  is  of  great 


die  for  circuminjecting  the  rectum. 


value,  for  example,  in  the  Whitehead  method  of  excision  of  hemorrhoids.  The  typical 
circuminjection  of  the  anus,  the  principle  of  which  was  first  described  by  Reclus, 
is  performed  in  the  following  manner:  Four  points  of  entrance  are  marked  in  the 
region  of  but  not  too  close  to  the  anus,  perhaps  2  to  3  finger-breadths  distant  from 
the  anal  orifice  (Fig.  161).  From  these  points  a  0.5  per  cent,  solution  of  novocain- 
suprarenin  is  injected  with  a  needle  10  cm.  long.  The  needle  is  first  inserted  perpen- 
dicularly at  one  of  the  lateral  points,  parallel  with  the  wall  of  the  rectum,  penetrating 
the  sphincter  and  the  levator  ani.    The  needle  is  partly  withdrawn  and  again  passed 


342 


LOCAL  ANESTHESIA 


deeply  to  its  full  length,  in  a  more  oblique  direction  toward  the  anterior  and  posterior 
walls  of  the  rectum.  The  direction  taken  by  the  needle  is  very  well  shown  in  Fig. 
162.  At  least  5  c.c.  of  0.5  per  cent,  novocain-suprarenin  solution  is  continuously 
injected  with  each  insertion  of  the  needle.  The  same  injection  is  made  into  the  three 
other  points  marked,  so  that  at  least  60  c.c.  of  the  solution  would  be  used  for  the 
entire  injection.  The  circuminjection  of  the  anus  is  made  from  one  point  to  the 
other  in  two  different  layers,  one  injection  into  the  sphincter  and  the  other  into  the 
subcutaneous  tissue  (Fig.  159).  For  this  20  c.c.  more  of  the  solution  will  be  used, 
making  altogether  100  c.c,  and  125  c.c.  in  fat  persons.  These  injections  can  be  made 
without  inserting  the  finger  into  the  rectum.  Occasionally,  when  the  position  of  the 
needle  seems  doubtful,  it  may  be  controlled  with  the  finger.     Anyone  who  is  inex- 


FiG.   163. — Para-anal  injection  under  guidance  of  the  finger. 

perienced  should  make  the  deep  injections  with  the  aid  of  the  guiding  finger  as 
shown  in  Fig.  163.  In  the  deepest  injections  the  point  of  the  needle  should  be  felt 
under  the  rectal  wall,  above  the  sphincter.  In  women  the  anterior  injection  is  con- 
trolled through  the  vagina.  If  in  anal  fissure  the  finger  cannot  be  introduced  on 
account  of  intense  pain,  it  is  well  to  follow  the  advice  of  Reclus  and  previously  make 
the  mucous  membrane  insensitive  by  inserting  cotton  tampons  soaked  in  an  anesthetic 
(2  per  cent,  alypin-suprarenin  solution).  An  experienced  person  can  dispense  with 
this  method.  The  sphincter  relaxes  in  a  very  few  minutes  after  the  circinninjection 
and  can  be  dilated,  excised,  or  cauterized  as  much  as  desired. 

In  complicated  cases  of  rectal  fistula  where  the  extent  cannot  be  exactly  estimated, 
it  is  advisable  to  proceed  as  in  operations  for  hemorrhoids,  and  circuminject  the 
entire  anus,  in  which  case  the  points  of  entrance  should  be  so  located  that  the  fistulous 


.J 


(;KxiTo~rRL\'ARy  axd  hectm.  operations 


343 


tract  is  situated  within  the  circimiiiijcctcd  area.  In  simple,  direct  fistula,  where  the 
probe  passes  directly  into  the  rectum  and  in  which  the  inner  opening  can  he  felt, 
and  diUitation  of  the  sphincter  is  not  necessary,  a  simpler  method  can  })e  used.  'I1u-ee 
points  of  entrance  are  marked  along  the  outer  opening  of  the  fistula  (Fig.  Kii)  and 
the  needle  is  inserted  into  each  of  these  points  and  from  them  continuous  injection 
is  made  down  to  the  mucous  membrane  of  the  rectum,  under  the  guidance  of  a  finger, 
close  to  the  inner  opening,  and  finally  a  subcutaneous  and  submucous  injection  is 
made  in  the  direction  of  the  dotted  line.  Sometimes  the  outlet  of  the  fistulous  tract 
lies  far  from  the  anus,  and  it  is  almost  impossible  to  determine  the  extent  of  the 


^*^ 


Fig.   164. — Technique  of  injection  for  simple  rectiil  fistula. 


operative  field.  In  such  cases  circuminjection  is  not  applicable  and  sacral  or  para- 
sacral conduction  anesthesia  is  more  suitable.  The  latter  is  also  an  excellent  method 
of  anesthesia  for  hemorrhoidal  operations,  but  it  lacks  the  advantage  of  the  anemia 
produced  by  suprarenin,  which  is  so  valuable  in  the  Whitehead  operation  for 
hemorrhoids.  Periproctitic  abscesses  are  best  opened  under  ether  or  ethyl  chlorid 
anesthesia. 

The  Excision  of  a  Carcinomatous  Rectum. — Excisions  and  resections  of  carcino- 
matous rectums  under  local  anesthesia  with  the  aid  of  parasacral  injections  (page 
320)  have  been  practised  for  so  short  a  time  that  it  is  impossible  as  yet  to  determine 
the  general  usefulness  of  this  method. 


CHAPTER  XVI. 

OPERATIONS  ON  THE   EXTRE^NIITIES. 

THE    USE    OF    LOCAL    ANESTHESIA    FOR    THE    REDUCTION    OF    FRACTURES 
AND    DISLOCATIONS. 

Local  anesthesia  can  be  used  in  various  ways  for  fractures  and  dislocations  of  the 
extremities.  Conduction  anesthesia  is  suitable  for  these  cases  just  as  for  other  opera- 
tions. Kulenkampff's  plexus  anesthesia  is  of  the  greatest  importance  in  this  connec- 
tion, because  it  brings  about  in  a  simple  manner  such  complete  motor  and  sensory 
paralysis  of  the  arm  and  the  shoulder  muscles  that  a  more  favorable  condition  cannot 
be  imagined.  Another  method  is  the  direct  injection  of  an  anesthetic  between  the 
fractured  ends  or  into  the  dislocated  joint  as  recommended  by  Lerda  and  Quenu. 
As  early  as  1885  Conway  attempted  to  produce  anesthesia  in  3  cases  of  fracture  of 
the  radius  by  injecting  cocain  solutions  between  the  broken  ends  of  the  bone. 
Furthermore,  Recliis  relates  one  case  of  fracture  of  the  tibia  in  which  he  injected  a 
cocain  solution  at  the  point  of  fracture,  in  order  to  facilitate  the  transportation  of 
the  patient.  He  states  that  the  fracture  immediately  became  painless.  There  are 
no  other  case  reports  on  this  subject  in  the  older  literature.  The  first  comprehensive 
reports  were  made  in  1907  and  1908  by  Lerda  and  Quenu,  the  former  reporting  30 
and  the  latter  15  fractures  in  different  parts  of  the  body  which  were  painlessly 
replaced  after  injections  of  cocain. 

After  establishing  the  diagnosis,  injections  of  an  anesthetic  solution  are  made 
from  various  points  and  in  different  directions  toward  the  ends  of  the  fracture. 
If  there  is  a  marked  dislocation  of  the  broken  ends,  particularly  in  the  long  axis  of  the 
bone,  injection  must  be  made  at  each  end  of  the  broken  bone.  In  limbs  having  two 
bones  each  fracture  must  be  treated  separately.  In  joint  fractures,  additional  injec- 
tions must  be  made  into  the  joint. 

Lerda  and  Quenu  used  a  0.5  per  cent,  cocain  solution;  one  added  suprarenin,  the 
other  omitted  it.  Conway  increased  the  effect  of  the  cocain  by  ligating  the  extremity. 
We  now  use  a  1  per  cent,  novocain-suprarenin  solution.  The  points  of  entrance  are 
previously  prepared  by  painting  with  iodin.  The  result  of  this  injection  is  very  sur- 
prising, almost  immediately  after  the  injection  the  pain  subsides,  and  a  few  minutes 
later  the  fracture  becomes  entirely  insensitive.  The  muscles  relax  as  in  general 
anesthesia. 


OPERATIONS  ON   THE  EXTREMITIES  345 

Conway  was  the  first  to  call  attention  to  the  use  of  intra-articular  injections  for 
dislocations  (replacements  of  a  dislocated  elbow).  In  1909  Quenu  reported  5 
cases  of  luxation  which  were  painlessly  replaced  in  this  manner  (two  shoulder 
dislocations,  1  elbow,  and  1  thumb  luxation,  and  one  ischiatic  dislocation  of  the  hip). 
The  injection  technique  is  very  simple.  The  anesthetic  (1  per  cent,  novocain-supra- 
renin  solution)  is  injected  both  at  the  proximal  and  distal  ends  of  the  dislocated  bones. 
Shortly  after  the  injection  the  limb  which  was  rigidly  fixed  becomes  movable  and 
painless  and  the  muscles  relax.  Occasionally  active  movements  and  pressure  on 
certain  spots,  the  latter  corresponding  to  the  muscular  attachments,  remain  painful. 
For  such  cases  Quenu  advises  that  more  of  the  anesthetic  be  injected  at  the  painful 
spot. 

The  following  table  shows  the  author's  experience  with  local  anesthesia  in  51  simple 
fractures  and  luxations: 


Plexus 
anesthesia. 

Other 
conduction 
anesthesia. 

Local 
injections. 

Typical  fracture  of  radius       .... 

Fracture  of  forearm 

Dislocation  of  elbow 

Supracondyloid  fracture  of  upper  arm  . 

Dislocations  of  shoulder 

Dislocations  of  the  foot 

.       .                 1 

.      .               7 

.       '.                4 
.      .               10 

'2 
3 
1 

3 
1 
1 
1 
5 

7 

1 

Posterior  dislocation  of  tibia        .      .      . 
Dislocation  of  hip-joint 

2 
2 

In  23  cases  local  injections  were  made  and  only  in  one  case  of  fracture  of  the  tibia 
did  they  prove  unsuccessful.  In  all  other  cases  there  was  complete  anesthesia,  and 
the  fractures  were  easily  and  painlessly  reduced. 

In  fracture  of  the  radius  10  c.c.  novocain-suprarenin  solution  were  injected  both 
from  the  extensor  and  radial  side  to  the  seat  of  fracture  and  some  into  the  wrist-joint. 
In  cases  of  fracture  of  both  bones  of  the  forearm  10  c.c.  was  injected  into  each  point 
of  fracture.  In  dislocations  of  the  elbow  an  injection  of  5  c.c.  was  made  from  behind 
through  the  triceps,  and  to  the  upper  end  of  the  joint  of  the  forearm,  and  also  freely 
around  the  lower  end  of  the  humerus.  In  a  case  of  supracondyloid  fracture  of  the 
upper  arm,  with  dislocation,  20  c.c.  were  injected  from  behind  in  various  directions 
about  the  seat  of  fracture  and  into  the  elbow-joint. 

In  5  cases  of  forward  dislocation  of  the  shoulder  10  c.c.  were  injected  through 
the  deltoid  muscle  from  without  into  the  joint  cavity,  and  the  same  quantity  was 
injected  around  the  luxated  head  of  the  humerus.  In  7  fractures  of  the  ankle,  15  c.c. 
were  injected  around  the  fractured  fibula  at  the  internal  malleolus  and  into  the 
ankle-joint. 


346 


LOCAL  ANESTHESIA 


In  2  cases  of  posterior  dislocation  of  the  tibia,  35  to  40  c.c.  were  injected  from  before 
and  from  both  sides  to  the  joint  ends.  The  intra-articular  injections  for  dislocation 
of  the  femur  mentioned  by  Quenu  are  most  interesting.  One  of  two  cases  of  this 
character,  a  recent  anterior  dislocation  of  the  hip  in  a  very  strong  miner,  about 
forty-five  years  of  age,  was  performed  under  this  method  as  follows:  From  two 
points  in  the  gluteal  region  25  c.c.  of  a  1  per  cent,  novocain-suprarenin  solution 
were  injected  with  a  long  needle  to  the  head  of  the  femur,  which  could  be  palpated 
and  felt  with  the  needle,  and  20  c.c.  of  the  solution  into  the  joint  cavity.  The 
dislocated  head  of  the  femur  cannot  be  used  as  a  landmark  for  inserting  the  needle 


iito  the  hip-joint  for  dislocation. 


into  the  joint  cavity  owing  to  its  changed  relative  position  to  the  cavity.  The  pelvic 
bone  must  be  used  as  a  guide.  A  point  close  behind  the  anterior  superior  spine  of 
the  ilium  (Fig.  165)  was  selected  for  the  entrance  of  the  needle  which  was  10  cm. 
long,  holding  a  bony  pelvis  next  to  the  patient  as  a  guide.  The  point  of  the  needle 
was  passed  along  the  bone  and  immediately  into  the  joint  cavity,  from  which  bloody 
synovial  fluid  was  removed.  Almost  immediately  after  the  injection  the  leg  which 
was  rigid  before  became  movable  and  after  ten  minutes  was  easily  replaced.  The 
patient  felt  no  pain  in  his  hip,  but  later  complained  of  the  firm  grip  of  the  per- 
sons who  were  replacing  the  bone.     The  other  case  was  an  obturator  dislocation 


OPERATIOSS  OX    Till':   EXTREMITIES  347 

of  thirty-six  hours'  (hiratioii  in  a  stroiii;-,  stahU'  hoy  a^vd  si'vcnteen  years.  Again 
25  c.c.  of  the  sohition  were  injected  into  the  joint  cavity,  2")  c.c.  around  the  head 
of  the  ftMuur,  which  could  be  felt  under  the  pubic  bone,  and  10  c.c.  more  into  a  spot 
on  the  outside  which  had  remained  very  sensitive.  Ten  minutes  after  the  first,  and 
flAc  minutes  after  the  second  injection  the  bone  was  easily  and  painlessly  replaced. 
No  bad  results  have  been  reported  from  the  use  of  local  anesthesia  in  fractures  and 
dislocations,  everything  points  to  its  surprising  advantages.  The  only  remote  danger 
in  using  the  local  injections  for  fractures  and  dislocations  is  the  possibility  of  infection. 
Such  a  danger  is  so  improbable  at  the  present  time  that  surgeons  daily  inject  into 
the  body  large  quantities  of  such  solutions,  and  therefore  there  is  no  reason  why  they 
should  not  be  also  injected  between  fractured  ends  and  into  the  joints. 

There  is  one  precaution  which  must  always  be  observed  in  making  these  local 
injections,  that  is,  the  points  of  entrance  should  never  be  placed  wdiere  there  is  an 
abrasion  of  the  skin,  or  where  it  is  crushed,  thinned,  or  soiled.  In  such  cases  the 
local  injections  are  best  supplanted  by  the  plexus  anesthesia  of  Kulenkampff,  which 
is  so  serviceable  in  dislocations  of  the  shoulder.  A  shoulder  dislocation  of  four  weeks' 
standing  can  be  replaced  with  ease  under  plexus  anesthesia. 

Local  injections  are  specially  recommended  for  fractures  of  the  lower  extremity. 
Lerda  and  Quenu  also  used  them  frequently  for  this  purpose.  The  advantages 
derived  from  the  use  of  local  anesthesia  in  the  treatment  of  fractures  are  so  evident 
that  they  only  need  to  be  mentioned. 

It  is  a  decided  technical  advantage  to  be  able  to  make  cases  of  elbow  and  forearm 
fracture  painless  without  a  general  anesthetic,  and  then  to  be  able  to  examine  the 
patient  under  the  Rontgen  screen  and  leisurely  decide  upon  the  best  method  for 
replacing  the  limb  and  the  best  position  in  which  to  place  it.  The  annoying  and 
sometimes  dangerous  excitability  of  the  anesthetized  patient  is  avoided  and  bandages 
are  more  easily  applied. 

Dislocations  are  much  more  easily  replaced  than  when  patients  ha\-e  had  general 
anesthesia.  If  plexus  anesthesia  is  used,  this  fact  is  readily  explained  by  the  more 
complete  relaxation  of  the  muscles.  Intra-articular  injections  decidedly  facilitate 
the  replacement  of  dislocations.  jNIention  should  be  made  of  the  communication  of 
Payr,  who  filled  the  luxated  joint  with  80  to  100  c.c.  of  0.5  per  cent,  novocain- 
suprarenin  solution  in  order  to  release  the  capsule  and  at  the  same  time  prepare 
a  way  for  the  dislocated  bone. 

OPERATIONS  ON  THE  UPPER  EXTREMITY. 

The  Sensory  Innervation. — The  brachial  plexus  supplies  the  entire  sensory  inner- 
vation of  the  arm  as  far  as  the  shoulder-joint,  and  merges  into  a  thin  nerve  trunk  after 


348 


LOCAL  ANESTHESIA 


leaving  the  opening  in  the  scalenus  muscle.    In  the  axilla  the  upper  intercostal  nerves 
supply  part  of  the  sensory  innervation,  and  one  of  them,  the  medial  brachial  cutaneous, 


Fig.  166.— Sensory  innervation  of  the  upper  extremity:  1,  supraclavicular;  2,  medial  brachial  cuta- 
neous; 3  anterior  brachial  cutaneous;  4,  medial  antibrachial  cutaneous;  5,  lateral  antibrachial  cutaneous; 
b,  dorsal  antibrachial  cutaneous;  7,  superficial  radial;  8.  palmar  branch  of  median  nerve;  9,  palmar 
branch  of  ulnar  nerve;  10,  dorsal  branch  of  ulnar  nerve;  11,  ulnar  nerve;  12,  median  nerve;  13,  lateral 
brachial  cutaneous. 


OPE  HAT  I  ox, S  OX   THE  EXTREMITIES  349 

supplies  also  a  part  of  the  skin  of  the  iijiper  arm.  On  the  other  hand,  the  skin 
of  the  shoulders  is  innervated  from  the  cervieal  i)lexus  by  the  supraclavieular 
nerves.  Fig.  166  shows  the  sensory  nerves  of  the  upper  extremity  as  they  emerge 
from  the  fascia  under  the  skin  and  their  peripheral  distribution.  It  is  well  to 
compare  this  with  the  scheme  of  Fig.  171  (page  354). 

The  details  of  the  innervation  will  be  considered  and  described  only  so  far  as 
they  are  concerned  in  the  techiiic[ue  of  the  anesthesia. 

Anesthesia  of  the  Brachial  Plexus. — Crile's  method  (page  102)  of  interrupting 
the  brachial  plexus,  after  freely  exposing  it  just  above  the  clavicle,  has  the  disad- 
vantage of  all  such  procedures,  and  therefore  has  not  become  popular.  Hirschel  was 
the  first  author  who  was  able  to  report  upon  the  possibility  of  anesthetizing  the  entire 
arm  (which  was  an  impossibility  before  the  introduction  of  suprarenin)  by  making  the 
injection  to  the  plexus  through  the  skin. 

He  selected  the  axilla  for  his  point  of  entrance.  As  high  up  in  the  axilla  as  possible 
a  pad  is  bound  to  the  thorax  by  two  elastic  bands  in  order  to  obtain  a  congestion  of 
the  vessels  for  the  purpose  of  slowing  the  process  of  absorption.  The  arm  is  strongly 
abducted,  the  axillary  artery  fixed  with  the  fingers  of  one  hand,  and  the  needle  inserted 
as  far  up  under  the  pectoralis  major  as  possible,  in  the  direction  of  the  long  axis  of 
the  arm.  Injection  must  be  made  as  soon  as  the  needle  is  entered,  which  will  cause 
the  vessels  to  slip  away  from  the  needle  and  thus  prevent  injury. 

Several  syringefuls  of  the  solution  are  injected  around  the  median  nerve  above 
and  around  the  ulnar  nerve  anteriorly.  One  further  injection  is  still  necessary  under- 
neath the  artery,  about  the  insertion  of  the  latissimus  dorsi  where  the  radial  nerve 
is  encountered.  In  this  manner  the  artery  is  circuminjected  and  with  a  little  caution 
any  lesion  to  the  artery  or  vein  can  be  avoided.  Hirschel  first  reported  three  injections 
successfully  carried  out  in  this  way,  and  later  reported  25  cases,  and  at  the  same  time 
mentioned  the  fact  that  he  considered  the  constriction  of  the  vessels  unnecessary; 
30  to  40  c.c.  of  2  per  cent,  novocain-suprarenin  solution  are  sufficient  for  this  anes- 
thesia. Soon  after  Hirschel's  first  report,  Ivulenkampft'  also  reported  25  cases  of  suc- 
cessful anesthesia  of  the  brachial  plexus.  For  blocking  he  chose  the  spot  where 
the  plexus  lies  on  the  first  rib,  lateral  to  the  subclavian  artery,  and  made  the  first 
experiments  upon  himself.  The  location  of  the  plexus  can  be  very  definitely  deter- 
mined, being  bounded  on  the  inner  side  by  the  subclavian  artery  whose  pulsations 
can  be  felt  below  by  the  first  rib  and  anteriorly  by  the  cla^•icle.  The  subcla\ian 
vein  lies  to  the  outer  side. 

The  daily  use  of  the  plexus  anesthesia,  according  to  Kulenkampff,  has  proved 
this  procedure  to  be  a  typical,  harmless,  very  simple,  and,  at  the  same  time, 
reliable  method  of  anesthesia.  It  is  suitable  for  all  operations  on  the  upper 
extremities  and  especially  for  the  replacement  of  shoulder  dislocation,  for  which 


350 


LOCAL  ANESTHESIA 


purpose  it  is  undoubtedly  far  superior  to  Quenu's  method  mentioned  above.  When 
it  is  used  for  operations  on  the  upper  extremity,  general  anesthesia  is  altogether 
superfluous.  Kulenkampff  has  recently  given  an  accurate  account  of  the  experience 
gained  in  his  first  160  cases.  The  anatomical  relations  of  the  point  of  injection  are 
shown  in  Kulenkampff 's  diagram  (Figs.  167  to  169).  Fig.  167  shows  the  position  of 
the  first  rib,  when  viewing  the  supraclavicular  region  from  the  side.  It  should  be 
noted  how  it  apparently  rises  perpendicularly  above  and  behind  the  clavicle.  This  is 
of  importance,  as  it  represents  the  lowest  point  to  which  the  properly  guided  needle 


Fig.  167. — Relation  of  first  rib  and  subcla-\rian  artery  to  the  cla\dcle  (Kulenkampff).  a,  scalenus 
medius  muscle;  b,  apex  of  lung;  c,  omohyoid  muscle;  d,  wheal;  e,  subcla^aan  artery  and  its  branch  the 
transverse  colli;  /,  scalenus  anticus  muscle;  g,  sternocleidomastoid  muscle. 


can  penetrate.  The  operator  does  not  experience  that  uncomfortable  feeling  of  insert- 
ing the  needle  to  a  great  depth,  without  feeling  any  resistance  and  not  knowing  the 
location  of  the  point  of  the  needle.  The  first  rib  crosses  the  clavicle  at  about  its  centre, 
which  is  the  spot  where  the  most  important  wheal  must  be  placed.  In  the  median 
line  the  arch  of  the  subclavian  artery  is  also  recognized,  as  it  extends  above  the 
clavicle  and  above  this  the  pleural  arch  makes  its  appearance,  which  is  otherwise 
covered  by  the  brachial  plexus.  Furthermore,  the  scalenus  anticus  is  recognized 
on  the  outer  edge  of  the  sternocleidomastoid  muscle  and  the  obliquely  ascending 


OPERATIONS  ON    THE  ENTh'EM ITI ES 


351 


omohyoid  is  seen  to  the  outer  side  of  tlie  (irst  ril).    It  is  cut  oil'  here,  in  order  to  sliow 
as  phiinly  as  i)ossible  the  direction  taken  hy  the  rih.      Fi<;-.   KIS  shows  the  relati\e 


Fig.  16S. — Relation  of  the  Ijrachial  plexus  to  clavicle  and  subclavian  artery  (Kulenkampff.)  a, 
omohj'oid  muscle;  b,  brachial  plexus  (partly  schematic);  c,  sul^clavian  artery  with  the  transverse  colli; 
d,  scalenus  anticus  muscle;  c,  sternocleidomastoid  muscle. 


Fig.  169. — Bony  thorax  from  above  (Kulenkampff)  showing  the  relation  of  the  plexus  and  sul)clavian 
artery  to  the  clavicle  on  one  side,  and  the  position  of  the  needle  on  the  other,  a,  subclavian  vein;  b, 
attachment  of  the  scalenus  anticus  muscle;  c,  subclavian  artery;  d,  brachial  plexus  surrounding  the  artery 
in  a  sickle-shaped  manner;  e,  attachment  of  the  scalenus  medius  muscle. 


352  LOCAL  ANESTHESIA 

positions  as  they  appear  after  the  removal  of  the  skin,  superficial  and  deep  fascia. 
The  transversus  colli  artery  is  seen,  as  it  usually  passes  in  the  midst  of  the  closely 
overlapping  nerve  trunks.  Fig.  169  shows  how  the  needle  should  be  introduced  in 
order  to  reach  the  first  rib.  Depending  upon  the  angle  at  which  the  cervical  verte- 
brae approach  the  sternum,  a  projection  of  the  axis  of  the  needle  would  strike  the 
second  to  fourth  spinous  process  of  the  dorsal  vertebra. 

On  the  opposite  side  the  plexus,  artery,  attachment  of  the  scalenus  muscle,  and  the 
vein  are  shown  particularly  with  reference  to  the  sickle  shape  of  the  cross  section.  It 
also  shows  how  the  artery  is  surrounded  by  nerve  trunks  immediately  under  the 
clavicle.  It  can  be  readily  seen  that  a  needle  inserted  close  to  the  artery  must  pass 
between  the  nerve  trunks  and  that  if  it  is  properly  inserted  it  will,  without  fail, 
transmit  the  pulsation  of  the  artery.  The  diagram  shows  the  narrow  slit  of  the 
scalenus  muscle  somewhat  more  plainly  than  Figs.  167  and  168. 


Fig.   170. — Plexus  anesthesia.     (After  Kulenkampff.) 

The  technique  of  the  injection  is  as  follows:  It  is  advisable  whenever  possible  to 
have  the  patient  in  the  sitting  posture  while  being  anesthetized  (Fig.  170).  The 
patient  needs  no  previously  administered  opiate,  but  he  should  certainly  be  informed 
of  the  paresthesia,  which  radiates  to  the  fingers  and  which  will  arise  when  the 
needle  penetrates  to  the  plexus,  and  he  should  be  instructed  to  state  when  he  feels 
these  sensations.  This  is  the  only  way  to  positively  determine  when  the  needle  has 
reached  the  right  spot.  The  next  step  is  to  palpate  the  subclavian  artery,  which  is 
done  by  making  gentle  pressure  with  the  finger.  In  many  cases  the  pulsation  is 
visible  more  often  to  the  right  than  to  the  left,  which  may  be  explained  by  varying 


J 


OPERATIONS  ON   THE   ENTh'EMlTIES  353 

anatomical  relations.  A  wheal  is  placed  directly  outward  from  the  spot  where  the 
artery  disappears  behind  the  edge  of  the  clavicle.  The  spot  almost  without  excei)tion 
will  correspond  to  the  middle  of  the  clavicle.  At  this  same  point,  as  a  rule,  a  downward 
prolongation  of  the  external  jugular  vein,  which  is  usually  visible,  also  crosses  the 
clavicle.  Here  we  insert  a  fine  needle  4  to  6  cm.  long,  without  syringe,  in  the  direction 
which  it  should  take  to  strike  the  spinous  process  of  the  second  or  third  dorsal 
vertebrae  (Fig.  169).  The  plexus  lies  rather  close  to  and  under  the  fascia.  As 
soon  as  the  needle  touches  it,  radiating  paresthetic  sensations  are  complained  of 
in  the  fingers  supplied  by  the  median  nerve  which  lies  superficially,  and  of  the  radial 
nerve  which  lies  deeper  and  posterior  to  the  median  nerve.  If  at  a  depth  of  1  to  3  cm. 
the  first  rib  is  felt,  it  indicates  that  the  plexus  must  lie  more  superficially.  If  pares- 
thesia is  not  obtained  at  once,  it  must  be  sought  by  slightly  changing  the  position  of 
the  needle,  ^'ery  often  from  an  unnecessary  anxiety  about  the  subclavian  artery 
the  needle  is  inserted  too  far  outward.  If  blood  flows  from  the  needle,  its  direction 
must  be  changed.  As  soon  as  paresthesia  occurs,  attach  the  syringe  to  the  needle 
and  inject  10  c.c.  of  a  2  per  cent,  novocain-suprarenin  solution.  If  paresthesia  evi- 
dences itself  in  the  region  supplied  by  the  median  nerve,  a  part  of  the  solution 
should  be  injected  a  few  millimeters  deeper.  Finally,  10  c.c.  more  are  injected  so 
as  to  be  distributed  in  the  immediate  surroundings,  the  direction  of  the  needle 
being  very  slightly  changed  during  this  injection. 

The  operator  should  not  make  the  injection  before  the  paresthesia  occurs.  If 
there  is  a  pronounced  paresthesia  of  the  median  as  w^ell  as  of  the  radial  nerve, 
it  indicates  that  a  complete  sensory  and  motor  paralysis  of  the  arm  will  occur 
after  one  to  three  minutes.  It  is  usually  necessary  to  wait  ten  to  fifteen  minutes, 
but  if  after  this  length  of  time  the  paralysis  is  not  complete,  it  will  be  advisable  to 
make  another  injection  of  5  to  10  c.c.  of  4  per  cent,  novocain-suprarenin  solution. 
Paresthesia  will  not  be  felt  after  this  latter  injection  and  results  are  more  or  less 
uncertain. 

Very  soon  after  the  injection  the  upper  arm  can  be  ligated  to  arrest  hemorrhage 
without  any  discomfort  to  the  patient.  For  this  purpose  use  Perthe's  compressor. 
Ligation  is  usually  necessary,  because,  after  blocking  the  brachial  plexus,  the  arm 
becomes  more  or  less  hyperemic  as  in  Haidenhain's  experiment.  The  evident  contrary 
action  of  suprarenin  in  not  causing  contraction  of  the  subclavian  artery  is  similar 
to  the  obser\ations  made  on  extremities  after  section  of  the  nerves. 

The  number  of  failures  which  will  result  will  depend  upon  the  experience  of  the 
surgeon.  Kulenkampff  reports  that  in  100  cases  anesthetized  by  eight  different 
surgeons,  in  4  cases  it  was  found  impossible  to  cause  paresthesia  and,  therefore,  the 
injections  were  ineffective.  In  19  other  cases  some  areas  supplied  by  certain  nerves 
were  not  completely  blocked,  but  in  most  cases  the  operations  could  be  performed. 
23 


354 


LOCAL  ANESTHESIA 


The  extent  of  the  anesthesia  following  the  injection  is  shown  in  Fig.  171.  There 
is  always  a  motor  paralysis  of  the  axillary  nerve.  It  is,  therefore,  rather  surprising 
that  the  skin  which  is  innervated  ])y  the  sensory  part  of  the  axillary  nerve,  as  is 


Fig.  171. — Sensory  tracts  of  upper  arm  (after  Toldt)  and  the  effect  of  blocking  the  brachial  plexus 
(after  Kulenkampff ) .  ■  anesthesia;  ++  hyperesthesia  or  not  paralyzed;  D  not  paralyzed:  1,  supra- 
clavicular nerves;  2,  lateral  brachial  cutaneous  (derived  from  the  axillary  nerve);  3,  cutaneous  branch  of 
the  anterior  brachial  (derived  from  the  medial  antibrachial  cutaneous) ;  4,  posterior  brachial  cutaneous 
(derived  from  the  radial);  5,  lateral  antibrachial  cutaneous  fderivcil  from  the  musculocutaneus;  6,  dorsal 
antibrachial  cutaneous  (derived  from  the  radial) ;  7,  medial  jialnKir  branch;  8,  superficial  branch  of  the 
radial;  9,  lateral  cutaneous  branch  (derived  from  the  iutiicn-fal  i :  10,  medial  brachial  cutaneous;  11, 
ulnar  branch  of  the  medial  antibrachial  cutaneous;  12,  volar  luanch  n{  the  medial  antibrachial  cutaneous; 
13,  palmar  cutaneous  branch  of  the  ulnar;  1-4,  dorsal  branch  of  the  ulnar;  15,  superficial  branch  of  the 
ulnar;  16,  digital  volar  (derived  from  the  ulnar);   17,  digital  volar  (derived  from  the  median). 


OPERATIOXS  OX    THE  EXTREMITIES  355 

taught  in  text-books  on  anatomy,  is  never  rendered  insensitive  but  is  either  hypes- 
thetic  or  not  aft'eeted  at  ah.  From  this  observation  it  is  probal)le  that  innervation 
of  these  parts  must  take  place  from  other  nerves,  probably  the  supraclavicular.  The 
anesthesia  produced  will  last  from  one  and  a  half  to  three  hours.  In  160  cases  Kulen- 
kampff  observed  no  injury  at  the  point  of  injection  and  no  post-operative  pains.  It 
is  possible  to  puncture  the  subclavian  artery  during  this  injection  but  this  accident 
is  absolutely  free  from  danger. 

Plexus  anesthesia  is  indicated  in  all  surgical  operations  about  the  arm,  whether 
they  be  bloodless  or  bloody,  except  those  which  can  be  more  readily  treated  by  local 
injections.  j\Iost  of  the  operations  for  which  we  use  the  plexus  anesthesia  are  severe 
injuries  to  the  hand  and  phlegmons  of  the  hand  and  forearm.  To  these  may  be  added 
all  amputations,  disarticulations,  and  resections  of  the  upper  extremity  and  reduction 
of  fractures  and  dislocations. 

A  painless  disarticulation  of  the  shoulder-joint  can  be  performed  after  blocking  the 
terminal  branches  of  the  supraclavicular  and  intercostal  nerves,  by  making  a  circular 
infiltration  with  a  0.5  per  cent,  novocain-suprarenin  solution  of  the  subcutaneous 
connective  tissue  at  the  shoulder-base,  extending  transversely  through  the  axilla  and 
over  the  shoulder. 

Jenkel,  Finsterer,  Borchers  and  Siebert,  have  reported  favorable  results  obtained 
with  Kulenkampff's  plexus  anesthesia.  As  a  result  of  plexus  anesthesia  Borchers 
observed  a  niotor  paresis  of  the  arm  which  lasted  four  weeks,  but,  as  the  author 
himself  asserts,  this  was  probably  due  to  the  fact  that  the  upper  arm  had  been  too 
tightly  ligated.  Hirschel  considers  his  injection  into  the  axilla  far  more  reliable  than 
those  made  in  the  supraclavicular  fossa.  He  thinks  the  latter  very  suitable  for  shoulder 
operations  or  for  the  reduction  of  shoulder  dislocations,  but  believes  they  cannot  be 
relied  upon  for  hand  and  finger  operations — -which  does  not  correspond  with  either 
our  experience  or  that  of  Borchers. 

Anesthesia  of  a  Finger,  According  to  Oberst. — This  anesthesia  is  based  upon  the 
fact  that  the  nerves  supplying  all  the  fingers  lie  in  the  subcutaneous  connective  tissue 
of  the  first  phalanx  (page  158).  Fig.  172  shows  schematically  a  cross  section  of  the 
first  phalanx.  The  main  nerve  trunks  are  indicated  by  black  dots.  The  most  impor- 
tant nerves  lie  toward  the  volar  surface,  close  to  the  flexor  tendons.  These  nerves 
divide  high  up  into  branches  which  extend  to  the  dorsal  side,  innervating  the  extensor 
surface  of  the  second  and  third  phalanges.  Under  the  skin  of  the  extensor  surface 
are  two  fine  nerve  branches  which,  as  a  rule,  do  not  extend  beyond  the  first  phalanx. 

The  anesthetic  must  be  injected  into  the  region  of  these  nerve  trunks.  For  this, 
two  points  of  entrance  will  be  necessary,  which  should  be  situated  on  the  side  of  the 
finger  more  toward  the  extensor  surface  (Fig.  172, 1,  2)  where  the  skin  is  least  sensitive. 
The  injection  is  begun  by  making  a  wheal  at  one  of  the  points  of  entrance  with  a  very 


356 


LOCAL  ANESTHESIA 


fine  sharp  needle.    The  needle  is  then  inserted  transversely  to  the  long  axis  of  the 
finger  (in  Fig.  173,  1  and  2,  the  position  of  the  needle  is  indicated  by  arrows)  injecting 


Fig.  172. — Anesthesia  of  Oberst.  Schematic  cross-section  of  the  base  of  a  finger.  1  and  2  points  for 
injection,  o,  flexor  tendon;  b,  bone;  c,  extensor  tendon.  The  nerves  are  indicated  by  black  dots.  Tlie 
arrows  indicate  the  direction  of  the  needle. 


Fig.   17.3. — Injection  of  the  finger,  according  to  Oberst. 


the  solution  under  the  skin  of  the  flexor  surface.  The  needle  is  now  removed  and 
again  inserted  into  the  same  spot,  now  insensitive,  in  order  to  inject  beneath  the 
skin  of  the  extensor  side.     The  solution,  which  should  saturate  the  subcutaneous 


OI'Kh'ATIOXS   OX    Till':   EXT  RE  MIT  IKS  P,,')? 

conneeti\'e  tissue  in  a  circular  manner,  outi'ht  to  be  so  distrihuted  that  tiie  flexor  side 
receives  a  little  more  than  the  extensor  side.  Inject  2  to  2.5  c.c.  of  a  2  per  cent,  novo- 
cain-suprarenin  solution.  It  is  necessary  to  wait  until  the  tip  of  the  finger  has 
become  insensitive  to  the  prick  of  a  needle,  which  usually  occurs  in  five  minutes.  The 
finger  is  then  totally  insensitive  and  any  operation,  either  bloody  or  bloodless,  can 
be  performed  (reduction  of  luxations).  This  method  is  suitable  for  felons  when  they 
do  not  extend  beyond  the  middle  phalanx.  Oberst's  method  of  ligating  the  finger 
before  making  the  injection  of  the  anesthetizing  solution  is  unnecessary  owing  to  the 
addition  of  the  suprarenin.  The  finger  arteries  are  end  arteries,  therefore  the  injec- 
tion of  suprarenin  into  the  finger  must  be  made  cautiously.  Even  if  the  subcutaneous 
connective  tissue  of  the  finger  is  filled  with  a  dilute  suprarenin  solution,  all  its  arteries 
will  contract  and  it  is  with  difficulty  that  the  suprarenin  is  eliminated.  The  condition 
is  similar  to  that  of  a  pediculated  skin  flap  (Fig.  174)  or  the  prepuce  (page  329). 

This  is  undoubtedly  responsible  for  the  disturbances  and  secondary  pains,  which 
are  frequently  noticed  after  finger  anesthesia.  These  disturbances  are  not  observed 
when  the  injection  is  carried  out  according  to  the  Oberst  method — namely,  ligating 
the  finger  before  injecting  1  to  2  c.c.  of  0.5  per  cent,  cocain  solution.  They  can  also 
be  a^•oided  if  the  injection  is  made  as  close  as  possible  to  the  base  of  the  finger,  where 
the  blood  supply  is  more  abundant,  and  if  the  subcutaneous  connective  tissue  is  not 
too  tensely  infiltrated  with  an  injection  of  too  large  a  quantity,  as  10  c.c.  of  0.5  per 
cent,  novocain-suprarenin  solution.  It  is  therefore  preferable  to  use  a  small 
quantity  of  2  per  cent,  novocain-suprarenin  solution  in  the  manner  described. 
Unilateral  injections  made  only  to  the  flexor  or  only  to  the  extensor  surface  are  seldom 
used.  Small  furuncles  on  the  extensor  side  of  the  first  phalanx  can  easily  be  made 
insensitive  by  a  fork-shaped  injection  (Fig.  172)  on  the  index  finger.^ 

Anesthesia  of  One  Finger  and  the  Surrounding  Part  of  the  Hand.— The  introduc- 
tion of  suprarenin  has  made  it  possible  to  work  out  several  methods  of  injection 
which  will  include  the  palm  and  which  would  otherwise  be  possible  only  by  ligating 
the  arm,  a  process  which  takes  up  much  time  and  is  very  disagreeable  to  the  patient, 
and,  therefore,  could  never  become  popular. 

In  order  to  make  one  finger  with  the  neighboring  part  of  the  palm  or  back  of  the 
hand  insensitive,  two  points  of  entrance  are  marked  on  the  back  of  the  interdigital 
folds  (Fig.  174)  1  and  2,  or  2  and  3. 

For  the  thumb  and  fifth  finger  the  points  of  entrance  are  placed  respectively  on 
the  outer  or  inner  edge  of  the  hand.    From  these  points  a  0.5  or  1  per  cent,  novocain- 

1  Inasmuch  as  the  fingers  and  toes  are  supplied  by  end  arteries,  I  would  suggest  that  novocain  he  used 
without  the  addition  of  suprarenin,  and  that  the  circulation  be  interrupted  by  a  narrow  elastic  band  in 
order  to  avoid  any  evil  effects  resulting  from  the  prolonged  constriction  of  the  vessels  from 
suprarenin. 


358 


LOCAL  ANESTHESIA 


suprarenin  solution  is  freely  injected  siibciitaneoiisly  in  a  direction  toward  the  points 
a  and  d  in  the  palm  and  b  or  c  on  the  back  of  the  hand.  Fig.  175  demonstrates  the 
direction  of  the  needle  for  injections  of  the  palm  from  one  of  the  interdigital  folds. 
Points  of  entrance  should  never  be  placed  in  the  palm,  as  the  skin  is  too  hard  and 


Fig.   174. — Fork-shaped  injection  of  the  index  finger.     Anesthesia  of  a  finger  with  portions  of  palmar 
and  dorsal  surface.     (Third  and  fourth  fingers.)     1  to  4  indicates  points  for  injection. 


Fig.   175. — Method  of  introducing  a  needle  through  an  interdigital  fold  to  the  hand. 


sensitive.  The  operation  should  not  be  begun  until  the  anesthesia  has  extended  to 
the  tip  of  the  finger  under  consideration.  A  free  infiltration  of  the  solution  mentioned 
can  be  made  ^Yithout  the  precaution  which  is  usually  necessary  for  injection  of  the 
fingers. 


OPElx'ATIOXS  OX   TIN':   KXTRFAl ITl I'.S 


359 


Disarticulation  of  the  Middle  Finger  at  the  Basal  Phalanx.      Operations  on  the 
Third  Metacarpal  Bone.     Four  i)()iiits  of  ciitraucc  must  he  uiarkcd  {Fi<;s.  ITO  and 


Figs  170  and  177.— Disarticulation  of  the  middle  fingor  and  thuinh  at,  the  base. 
Operations  upon  a  metacarpal  bone. 


360 


LOCAL  ANESTHESIA 


177);  two  of  them  in  the  interdigital  fold,  two  on  the  back  of  the  hand  to  the  right 
and  left  of  the  third  metacarpal  bone  and  over  the  spaces  between  the  bones.  Two 
injections  are  made  from  points  3  and  4.    Fig.  178  shows  a  cross-section  through  the 


Fig.   178. — Cross-section  through  the  middle  of  the  hand.     Direction  of  the  needle  in  the 
interosseous  spaces.    3,  4,  and  b  correspond  to  similar  points  of  Figs.  176  and  177. 


Fig.   179. — Method  of  injecting  an  interosseous  space. 


OPEIyWTIOXS  OX    Till':   EXT  RE  MIT  I  F.S  'M\\ 

palm,  and  indicates  tlu-  direction  which  the  needle  nuist  take,  l-'or  this  injection 
the  operator  places  the  tip  of  his  left  index  fin<>er  into  the  patient's  palm  and  inserts 
the  needle  at  points  3  and  4,  making  constant  injection  directly  through  the  space 
which  lies  between  the  bones,  until  the  point  is  felt  beneath  the  skin  of  the  palm  at 
l)oint  (6).  Fig.  179  demonstrates  the  technique  of  this  injection.  For  each  of  the 
two  injections  5  c.c.  of  0.5  per  cent,  novocain-suprarenin  solution  will  be  required. 
These  injections  are  followed  by  the  infiltration  of  the  subcutaneous  connective  tissue 
from  points  1  and  2  toward  point  h  in  the  palm,  and  on  the  back  of  the  hand  toward 
j)oints  3  and  4.  Finally,  points  3  and  4  are  joined  by  a  subcutaneous  injection.  Alto- 
gether 30  to  40  c.c.  of  0.5  per  cent,  novocain-suprarenin  solution  are  required.  The 
anesthesia  is  completed  when  the  tip  of  the  middle  finger  has  become  insensitive. 
The  finger  can  now  be  disarticulated,  with  or  without  remo^'ing  its  metacarpal  bone. 
It  is  unnecessary  to  ligate  the  hand.  This  same  method  is  used  for  operation  on  the 
third  metacarpal  bone. 


The  Disarticulation  of  the  Thumb  at  the  Basal  Phalanx.  Operations  on  the  First 
Metacarpal  Bone  (Fig.  174). — The  injection  between  the  bones  is  l)egun  from  point 
11  an<l  the  needle  is  inserted  until  felt  under  the  skin  of  the  palm  at  point  a.  On 
account  of  the  thickness  of  the  soft  parts  10  c.c.  of  0.5  per  cent,  novocain-supra- 
renin solution  will  be  necessary.  The  next  step  is  a  subcutaneous  injection  from 
points  5  and  7  in  the  palm  toward  point  a  and  on  the  back  of  the  hand  toward  jjoint 
6.  It  is  unnecessary  to  ligate  the  arm.  About  50  c.c.  of  0.5  per  cent,  novocain- 
suprarenin  solution  are  necessary.  This  procedure  shows  at  once  that  it  is  possible 
to  make  the  thenar  eminence  insensitive  without  penetrating  the  sensitive  skin 
of  the  palm.  This  method  can  also  be  used  for  anesthesia  of  the  fifth  finger  and  its 
metacarpal  bone. 


362 


LOCAL  ANESTHESIA 


Anesthesia  of  Several  Fingers  and  Parts  of  the  Palm  (Figs.  180  and  181).  Points 
1,2,  3  are  used  for  anesthesia  of  the  second  and  third  fingers  and  are  marked  by  wheals. 
The  injection  in  the  interosseous  spaces  should  be  made  from  point  2  toward  point  a 
and  a  subcutaneous  infiltration  is  made  from  points  1  and  3  in  the  palm  toward  point 
a  and  on  the  back  of  the  hand  toward  point  2.  The  points  of  entrance,  4,  5,  6,  are 
used  in  the  same  manner  for  anesthetizing  the  fourth  and  fifth  fingers  at  the  same  time. 
If  necessary,  parts  of  the  palm  can  be  included  in  the  anesthetized  area  by  placing 
the  points  of  injection  2  or  6  closer  to  the  fingers  or  the  wrist,  as  the  case  may  be; 
50  c.c.  of  0.5  per  cent,  novocain-suprarenin  solution  are  necessary. 


Figs.   182  and  183. — Anesthesia  of  a  part  of  the  palm. 


Operations  on  Soft  Parts  of  the  Palm. — The  technique  of  the  anesthesia  of  the 
thenar  and  hypothenar  eminences  by  circuminjection  has  already  been  described 
in  connection  with  disarticulation  of  the  thumb.  Every  other  part  of  the  palm  can 
be  treated  in  the  same  way.  The  points  of  entrance  (usually  two)  should  always 
be  placed  on  the  side  of  the  hand  and  on  the  back  of  the  interdigital  folds.  For 
example,  we  will  select  a  field  of  operation  which  is  limited  to  the  soft  parts  of  the 
palm,  above  the  index  finger  (Figs.  182  and  183).  In  this  case  the  points  of  entrance 
are  marked  1  and  2.  From  both  of  these  points  a  free  injection  of  30  to  40  c.c.  of 
0.5  per  cent,  novocain-suprarenin  solution  is  made  toward  point  a  in  the  palm.  In 
case  of  phlegmon  of  the  hand,  injections  near  the  diseased  parts  must  be  avoided. 
Preferably  they  should  be  rendered  insensitive  by  plexus  anesthesia.    Abscesses  are 


Ori<:RATI()XS  ON   THE  EXTREMITIES 


aC)^ 


opened  more  quickly  and   l)etter  under  ethyl  chloride  anesthesia,  as  reconiniended 
by  Kulenkani])!!'. 

Operations  on  the  Soft  Parts  of  the  Back  of  the  Hand.  In  this  rcuion  operations 
are  usually  aseptic,  such  as  the  treating  of  injuries,  extirpation  of  ganglia,  hygromata, 
and  tumors.  The  field  of  operation  is  circuminjected  with  0.5  per  cent,  novocain- 
suprarenin  solution.  Fig.  184  shows  a  number  of  possibilities  for  circuminjection. 
I  n  most  cases  it  will  only  be  necessary  to  circuminject  three  sides  of  the  field  of  opera- 
tion in  a  fork-shaped  or  U-shaped  manner,  since  the  innervation  to  the  field  of  opera- 
tion is  derived  exclusively  from  the  arm.  A  three-sided  circuminjection  of  the  field 
of  operation  is  usually  sufficient  to  produce  peripheral  anesthesia.  If  the  circum- 
injection is  first  made  under  the  tendons  and  then  subcutaneously,  the  anesthesia 
will  not  be  limited  to  the  skin  and  subcutaneous  connective  tissue.  For  aseptic 
operations  on  the  back  of  the  hand  it  is,  therefore,  never  necessary  to  administer  a 
general  anesthetic. 


Fig.   184. — Anesthesia  of  the  soft  parts  of  the  back  of  the  hand. 


Blocking  the  Ulnar  Nerve  at  the  Elbow. — ^This  nerve  blocking  was  introduced  by 
Krogius  and  is  easily  done  and  very  reliable,  as  can  be  demonstrated  on  one's  own 
arm.  The  nerve  which  usually  lies  above  the  inner  condyle  of  the  humerus  is  plainly 
felt  as  it  rolls  between  the  fingers,  the  pressure  causing  the  patient  to  complain  of  a 
peculiar  sensation.  The  nerve  is  then  fixed  with  the  thumb  and  left  index  finger 
and  the  needle  is  inserted  into  it  through  the  subcutaneous  cellular  tissue  and  fascia. 
At  the  moment  when  the  point  of  the  needle  touches  the  nerve  and  penetrates  it 
the  patient  again  experiences  the  same  paresthesia  as  is  felt  when  pressure  is  made 
on  the  nerve,  which  indicates  that  the  needle  is  in  the  proper  place  for  the  injection 
of  the  anesthetizing  solution.  It  must  be  remembered  that  in  some  few  persons,  when 
the  forearm  is  bent,  the  trunk  of  the  ulnar  nerve  is  situated  in  front  of  and  not  behmd 
the  inner  condyle  and  only  slips  behind  when  the  arm  is  extended;  a  subcutaneous 


364 


LOCAL  ANESTHESIA 

Fig.  1S5 


Figs.  185  and  ISG. — Anesthesia  following  the  blocking  of  the  ulnar  nerve  at  the  elbow. 


OPEJLATIOXS  OX    THE   EXTREMITIES 


3(io 


or  subfascial  injection  in  this  position  will  naturally  he  incfiVctivc.  Fi^s.  is,")  and  180 
show  the  extent  of  the  anesthesia  which,  as  a  rule,  occurs  innnediately  after  the  injec- 
tion. This  shows  the  adaptability  of  this  form  of  anesthesia  for  operations  on  the 
fifth  finger,  the  hypothenar  eminence,  the  ulnar  edge  of  the  hand,  and  the  fifth 
metacarpal  bone. 

For  disarticulation  of  the  fifth  finger  and  other  operations  in  this  region  there  is 
no  simpler  method  of  anesthesia.  During  this  operation  ligation  is  necessary  and 
should  be  applied  before  the  operation  to  the  forearm  above  the  w-rist,  where  it  does 
not  annoy  the  patient. 


Flexor 
Flexor  ulnnris  #'  I    Median  nerre 

I'liliii.  long.  muKcIe 

Fig.  1S7. — Cross-section  through  the  forearm  above  the  wrist-joint. 


Anesthesia  of  the  Whole  Hand. — The  following  nerves  extend  from  the  forearm 
to  the  hand :  the  ulnar,  median,  and  interosseous,  all  of  w^hich  lie  in  the  deep  fascia,  and 
the  terminal  branches  of  the  radial  nerve  which  are  placed  subcutaneously.  Fig.  187 
is  a  cross  section  through  the  forearm  just  above  the  wrist.  The  tAvo  arrows  indicate 
the  direction  in  which  the  needle  should  be  inserted  for  blocking  the  median  and  ulnar 
nerves.  In  order  to  block  the  median  nerve,  a  point  of  entrance  (Fig.  188)  is  marked 
toward  the  ulnar  side,  close  to  the  tendon  of  the  palmaris  longus.  The  needle  is 
inserted  through  the  fascia  underlying  the  tendon  mentioned.  Search  is  then  made 
until  the  point  of  the  needle  strikes  the  nerve  trunk.  The  patient  should  be  requested 
to  say  when  radiating  paresthetic  sensations  are  felt;  5  c.c.  of  2  per  cent,  novocain- 
suprarenin  solution  are  then  injected  and  5  c.c.  of  the  same  solution  are  injected  from 
the  ulnar  edge  of  the  forearm  above  the  pisiform  bone  and  under  the  flexor  ulnaris. 
Finally,  the  subcutaneous  cellular  tissue  around  the  forearm  is  infiltrated  from  the 
same  point  and  possibly  2  or  3  others,  and  on  the  extensor  side  the  subfascial  tissue 
is  also  infiltrated  between  the  tendons  down  to  the  interosseous  ligament  with  50  to 
60  c.c.  of  0.5  per  cent,  novocain-suprarenin  solution. 


366 


LOCAL  ANESTHESIA 


Operations  on  the  Forearm. — The  skin  and  subcutaneous  connective  tissue  of  the 
forearm  to  tlie  lower  third  is  exclusively  innervated  by  long  subcutaneous  nerves 
which  emerge  from  the  fascia  above  the  elbow  (medial,  lateral  and  dorsal  ante- 
brachial cutaneous  nerves,  Fig.  164).  Consequently  the  infiltration  of  a  transverse 
strip  of  the  subcutaneous  cellular  tissue  of  the  forearm  results  in  anesthesia  extend- 
ing more  or  less  peripherally  from  the  point  of  injection,  and  if  the  subcutaneous 
cellular  tissue  is  infiltrated  circularly  close  above  or  below  the  elbow  with  a  0.5  per 
cent,  novocain-suprarenin  solution,  the  anesthesia  will  extend  to  the  lower  third 
of  the  forearm  in  every  direction.     This  method  has  no  more  practical  value  than 


Fig.   188. — Points  for  injecting  the  median  and  ulnar  nerves  above  the  wrist-joint. 


the  more  easily  accomplished  blocking  of  the  individual  nerve  trunks  mentioned. 
Conduction  anesthesia  of  the  lateral  antebrachial  cutaneous  nerve,  as  it  emerges 
from  above  the  elbow  on  the  lateral  edge  of  the  biceps  and  passes  into  the  subcu- 
taneous cellular  tissue,  has  a  historical  value,  for  Corning  in  1885  observed  for  the 
first  time  in  a  human  being  the  peripheral  extension  of  skin  anesthesia  following  an 
injection  of  cocaine  made  at  the  point  of  emergence  of  this  nerve. 

In  anesthetizing  for  operations  the  following  observations  should  be  made:  Opera- 
tions on  the  upper  two-thirds  of  the  forearm,  limited  to  the  skin  and  the  subcuta- 
neous cellular  tissues,  are  circuminjected  with  a  0.5  per  cent,  novocain-suprarenin 


OPKh'ATIONS   ON   THE   EXTUKM ITl ES 


3()7 


solution  in  a  U-shaped  manner  (Fig.  184).  'I'lir  unilateral  iimcrxation  of  this 
region  makes  circuminjection  unnecessary.  In  i\\v  lower  third  of  the  forearm  the 
U-shaped  circuminjection  shoukl  always  be  made  subfascially,  because  it  is  here  that 
the  nerves  emerge  (Fig.  166).  This  fact  might  possibly  frustrate  the  result  of  a  purely 
subcutaneous  circuminjection.  All  circumscribed  tumors  can  be  circuminjected  accord- 
ing to  Fig.  30  (page  192)  in  a  pyramidal  or  cup-shaped  manner.  Large  anesthetic  areas 
on  the  extensor  surface  of  the  lower  third  of  the  forearm  can  be  obtained  in  the  follow- 


FiG.   189.— U-shaped  injectit 


1  and  back  of  hand. 


ing  manner  (Fig.  189):  Two  points  of  entrance  are  marked  at  the  same  height  on 
tii-j  extensor  side  of  the  forearm  at  a  point  corresponding  to  the  palpable  edge  of  the 
uiua  and  radius.  Betw^een  these  points  all  the  soft  parts  of  the  extensor  side,  first 
the  muscles  and  then  the  subcutaneous  cellular  tissue,  are  infiltrated  transversely 
to  the  long  axis  of  the  arm  with  40  to  50  c.c.  of  0.5  novocain-suprarenin  solution. 
From  both  these  points  of  injection  strips  should  be  injected  subcutaneously  to  the 
wrist  and,  when  necessary,  to  the  fingers,  for  which  purpose  more  points  of  entrance 
may  be  required.     It  is  unnecessary  to  ligate  the  arm  during  the  operation.    This 


368 


LOCAL  ANESTHESIA 


method  can  be  used  for  the  treatment  of  any  injury  to  the  soft  parts  and  for  extirpa- 
tion of  tumors,  hygromata,  and  tendon-sheath  tuberculosis  in  this  region. 

A  corresponding  method  on  the  lower  half  of  the  flexor  side  of  the  forearm  is  carried 
out  a  little  differently  on  account  of  the  ulnar  and  median  nerves.  The  two  points 
of  entrance  are  again  marked  on  the  side  of  the  forearm  and  are  connected  by  infiltra- 
tion across  the  forearm,  at  first  close  to  the  bone  and  interosseous  ligament  and  then 
by  infiltration  of  the  subcutaneous  cellular  tissue.  It  is  unnecessary  to  infiltrate  all 
the  muscles,  in  fact  that  is  hardly  possible,  and  does  not  result  in  a  blocking  of  the 
ulnar  and  median  nerves.  If  the  field  of  operation  lies  within  the  area  supplied  by 
the  ulnar  nerve,  this  nerve  should  be  blocked  at  the  elbow  (page  363),  and  if  it  lies 
in  the  territory  of  the  median  nerve  this  nerve  should  be  sought  at  the  upper  end  of 
the  incision  and  blocked  by  intraneural  injection,  just  as  soon  as  it  is  exposed,  during 
the  operation.  It  will  be  necessary  to  ligate  the  arm  during  this  operation  and,  there- 
fore, anyone  who  is  familiar  with  plexus  anesthesia,  will  prefer  it  in  this  case.  Phleg- 
mons, bone  operations,  extensive  operations  on  the  soft  parts  of  the  upper  half  of 
the  forearm,  and  amputations  are  performed  under  plexus  anesthesia. 


Fig.  190. — Horseshoe  shape  injection  of  the  elbow-joint. 


Operations  on  the  Elbow. — A  U-shaped  infiltration  of  40  c.c.  of  0.5  per  cent,  novo- 
cain-suprarenin  solution  into  the  subcutaneous  cellular  tissue  of  the  back  of  the 
elbow  from  two  points  of  entrance  (Fig.  190,  1  and  2)  will  be  sufiicient  for  extirpation 
of  an  olecranon  bursa.  For  suturing  a  fractured  olecranon  process,  two  extra  points 
of  injection  should  be  marked  (Fig.  185,  3  and  4).  An  injection  of  20  c.c.  of  0.5  per 
cent,  novocain-suprarenin  solution  is  first  made  into  the  elbow-joint  beneath  the 
outer  or  inner  condyle.  From  each  of  the  points  1  and  2,  10  c.c.  of  the  solution  are 
injected  under  the  triceps  tendon  and  from  each  of  the  points  3  and  4,  10  c.c. 
are  injected  into  the  inner  and  outer  muscles  covering  the  ulna.  Finally  a  U-shaped 
subcutaneous  injection  is  made. 

In  order  to  perform  an  aseptic  arthrotomy  (for  removal  of  loose  bodies  in  joints) 
20  c.c.  of  a  0.5  per  cent,  novocain-suprarenin  solution  are  injected  into  the  joint 
and  the  capsule  and    the   subcutaneous   cellular   tissue   is   infiltrated   in  the  line 


ori'Jhwrioxs  ox  tiik  kxthemitiks  3(19 

of  iiK'ision.  For  resections  and  disarticulations  it  is  better  to  use  the  plexus 
anesthesia,  which  excels  venous  anesthesia  in  simplicity  and  comfort  hotli  for  the 
patient  and  the  physician. 

Operations  on  the  Upper  Arm. — Anesthetizing  local  injections  only  must  be  con- 
sidered for  superficial  oj^erative  procedures.  Simple  subcutaneous  circuminjections 
are  not  always  successful,  owing  to  the  numerous  and  irregular  points  of  emergence 
of  the  nerves  (Fig.  166).  Therefore,  it  is  always  necessary  to  make  a  complete  pyram- 
idal or  encasing  circuminjection  of  the  field  of  operation  (page  191).  In  order  to 
make  the  skin  of  the  entire  outer  surface  of  the  upper  arm  sufficiently  insensitive 
for  the  removal  of  Thiersch's  grafts  or  Kraus's  skin  flap,  the  entire  subcutaneous 
cellular  tissue  should  be  infiltrated  in  layers  as  far  as  it  is  necessary  with  a  0.5  per 
cent,  novocain-suprarenin  solution  in  the  same  manner  as  will  be  described  for  the 
thigh.  Complicated  operations  on  the  upper  arm,  bone  operations  and  dislocations 
should  be  performed  under  plexus  anesthesia. 

Operations  in  the  Shoulder  Region. — Large  lipomata  of  the  shoulder  region  are 
very  easily  rem()^•e(l  under  local  anesthesia.  A  number  of  points  of  entrance  should 
be  marked  around  the  tumor.  From  these  points  the  whole  base  of  the  tumor  is 
systematically  circuminjected  with  long  needles.  Finally  the  points  of  entrance 
are  joined  by  subcutaneous  injection  strips;  0.5  no^■ocain-suprarenin  solution  is  the 
proper  anesthetic  to  be  used.  Large  lipomata  will  freciuently  require  from  200  to 
250  c.c.  of  the  solution.  Operations  on  the  shoulder-joint  are  best  performed  under 
plexus  anesthesia,  according  to  the  method  of  Kulenkampff.  jNIethods  have  already 
been  mentioned  for  disarticulations  of  the  shoulder-joint.  For  this  purpose  the 
plexus  must  be  blocked  and  besides  this  the  subcutaneous  cellular  tissue  at  the 
base  of  the  limb  (/.  e.,  from  the  acromion  process  across  the  axilla)  must  be  circularly 
infiltrated  with  a  0.5  per  cent,  novocain-suprarenin  solution.  Lender  local  anesthesia 
and  by  the  anterior  incision  of  Langenbeck  the  anther  has  often  resected  a  joint 
and  reduced  by  operation  irreducible  axillary  dislocations  of  the  humerus  and  twice 
has  operated  for  fractures  of  the  upper  end  of  the  humerus.  Besides  blocking  the 
brachial  plexus  the  line  of  incision  is  freely  infiltrated  with  0.5  per  cent,  novocain- 
suprarenin  solution,  whereby  the  bleeding  is  decidedly  lessened.  A  shoulder-joint 
may  be  resected  either  b}'  a  posterior  incision,  according  to  Kocher,  or  by  the 
deltoid  incision,  which  is  preferred  in  complicated  cases.  For  the  last  mentioned 
incision  the  same  method  is  used  as  described  for  disarticulations.  For  Kocher's 
incision  it  will  probably  be  necessary  to  block  the  lower  branches  of  the  cervical 
plexus  according  to  Kappis,  or  from  the  side  (page  268)  by  infiltration  toward 
the  transverse  processes  of  the  cervical  vertebrae.  For  all  these  operations  we  can 
certainly  dispense  with  general  anesthesia.  For  performing  minor  operations  on  the 
clavicle,  for  example,  the  chiseling  of  a  disturbing  callus  (Fig.  191),  the  entire  bone 
24 


370 


LOCAL  ANESTHESIA 


must  be  circuminjected  from  two  points  of  entrance  in  a  trough-like  manner,  according 
to  the  diagram  shown  in  Fig.  32  (page  192). 


Fig.   I'Jl. — Trough-sliape  circuiuiiijection  of  the  clavicle. 


OPERATIONS    ABOUT    THE   LOWER   EXTREMITY. 

Sensory  Innervation. — The  foot  and  leg  are  supplied  by  the  sciatic  and  anticrural 
nerves  entirely,  while  a  great  number  of  other  nerves  are  concerned  in  the  sensory 
innervation  of  the  upper  thigh,  some  of  which  reach  the  thigh  directly  from  the  pelvis. 
The  most  important  of  these  are  the  obturator  posterior  and  lateral  femoral 
cutaneous,  while  the  others,  the  iliohypogastric,  ilio-inguinal,  genitocrural,  and  the 
superior  gluteal  supply  the  innervation  of  the  skin  at  the  base  of  the  thigh. 

Figs.  192  and  193  schematically  show  the  points  of  exit  of  the  sensory  nerves  and 
their  peripheral  distribution  to  the  lower  extremity. 

Conduction  Anesthesia  of  the  Thigh.— The  conditions  for  anesthesia  of  the  lower 
extremity  by  central  conduction  anesthesia  are  much  more  unfavorable  than  they 
are  for  the  arm,  for  in  the  arm  the  main  nerve  trunks  originating  from  the  cervical 
plexus  form  a  single  cord,  while  in  the  lower  extremity  at  least  five  nerves  must  be 
blocked  separately.  Blocking  the  lateral  cutaneous  femoral,  which  innervates  the 
skin  of  the  upper  thigh,  was  described  by  Nystrom  in  1909.  This  nerve  emerges  close 
beside  and  medial  to  the  anterior  superior  spine  of  the  ilium  under  Poupart's  ligament 
(Fig.  194).     Running  for  a  short  distance  downward  under  fascia  lata,  it  penetrates 


...    ] 


Ori'JRATIOXS  ON    THE   EXTRKM ITIES 


371 


it  in  one  or  more  ])l;iees,  and  thus  reaches  the  snbcntaneous  celhihir  tissnc  and  the 
skin.    In  order  to  hUx-k  tlietrnnk  of  tlic  nerve,  Laewen  snjx.uests  that  a  i)()int  of  entrance 


Figs.  192  and  19.3. — Scheme  of  sensory  innervation  of  the  lower  extntnitj:  1,  ilioh.Niiogastric; 
2,  lateral  femoral  cutaneous;  3,  lumbo-inguinal;  4,  anterior  femoral  cutaneous;  5,  oliturator;  G,  lateral 
sural  cutaneous  7,  saphenous;  8,  superficial  peroneal;  9,  sural;  10,  deep  peroneal;  11,  superior  gluteal; 
12,  inferior  gluteal;  13,  posterior  femoral  cutaneous;  14,  medial  sural  cutaneous;  15,  tibial  cutaneous 
branch;  16,  tibial. 


372 


LOCAL  ANESTHESIA 


be  marked  two  finger-breadths  inward  and  downward  from  the  anterior  superior 
spine  of  the  ihum  (Fig.  195).  From  this  point  an  injection  is  made  transversely  out- 
ward as  well  as  below  and  beyond  the  spine.  Two  injections  consisting  of  2.5  c.c. 
of  2  per  cent,  novocain-suprarenin  solution  each  are  made,  one  under  the  fascia 
and  the  other  under  the  skin.  The  ner^'e  will  then  be  blocked.  Nystrom  advised 
this  method  for  the  removal  of  epithelial  grafts  from  the  outer  side  of  the  upper  thigh. 


Ant.  .nip.  spine 


Lat.  cnfa.  femoris  nerve 


Pecfineus  muscle 


Fig.   194. — Cross-section  through  the  thigh  below  Poupart's  ligament. 


Unfortunately  it  is  unreliable,  a  fact  which  Laewen  has  also  noted,  because  the  extent 
of  skin  anesthesia  resulting  from  the  injection  is  so  variable  and  often  very  small. 
Laewen  therefore  advises  that  besides  the  nerve  mentioned,  the  anterior  crural  nerve 
should  also  be  blocked.  This  nerve  lies  a  little  outward  from  the  femoral  artery,  and 
is  separated  from  it  by  a  strip  of  fascia  (ileopectineal  ligament)  and,  as  a  rule,  by  a 
layer  of  iliopsoas  muscle.     It  frequently  does  not  lie  close  under  the  fascia  lata,  but 


OPERATIOXS   OX    TIN-:    EXTREMITIES 


373 


deeper  in  a  connective  tissue  sci)tuni  of  the  nnisclc  niciitioiict-1.  These  conditions 
are  shown  in  Fig.  104.  Laewen  tiierefore  gi\es  the  following  directions:  The  pulse 
of  the  femoral  artery  should  he  i)alpated  under  Poupart's  ligament.  The  fingers  of 
the  left  hand  should  remain  upon  the  artery,  so  as  to  he  constantly  assured  of  its 
position.  A  point  of  entrance  is  marked  just  under  Poupart's  ligament  about  1  to 
1.5  cm.  outward  from  the  spot  where  the  pulse  of  the  artery  is  palpable  (Fig.  195). 
From  this  point  a  fine  needle  is  inserted  perpendicularly  and  the  fascia  lata,  which 
is  easily  felt,  is  penetrated;  5  c.c.  of  2  per  cent,  novocain-suprarenin  solution  should 
be  injected,  inserting  the  needle  0.5  to  1  cm.  deeper  during  the  injection.  To  this 
should  be  added  that  the  point  of  the  needle  must  touch  the  nerve. 


Fig.  195. — Points  for  inject 


lateral  femoral  cutaneous;  2,  for  the  femoral. 


At  the  moment  when  the  nerve  is  touched  a  very  characteristic  contraction  of  the 
muscles  of  the  thigh  is  noted,  and  if  the  injection  is  then  made,  the  blocking  will  be 
completed  in  a  few  minutes.  The  most  striking  feature  is  the  motor  paralysis  of 
the  quadriceps  femoris  muscle.  In  this  case  Laewen's  novocain-bicarbonate  solu- 
tion is  unnecessary.  While  the  blocking  of  the  crural  nerve  alone  has  as  little 
practical  significance  as  the  blocking  of  the  lateral  femoral  cutaneous  alone,  never- 
theless the  blocking  of  both  nerves  conjointly  furnishes  a  very  large  anesthetic  field 
which  is  very  constant  in  extent.  The  limit  of  tlie  field  of  anesthesia  is  shown  by 
Figs.  196  and  197. 

Laewen  recommends  his  method  especially  for  removal  of  epithelial  grafts,  for  which 
purpose  it  gives  surprisingly  good   results.     In  this  manner  he  was  also  able  to 


374 


LOCAL  ANESTHESIA 


remove  painlessly  a  large  lipoma  from  the  rectus  femoris  muscle.  The  simultaneous 
blocking  of  the  anterior  crural  nerve  and  the  lateral  femoral  cutaneous  is  a  simple 
method,  and  one  that  can  be  generally  used  for  all  suitable  cases.  On  the  other 
hand,  those  nerves  which  emerge  from  the  pelvis  and  are  distributed  to  the  thigh 
are  reached  with  difficulty. 


Figs.   196  and   197. — Extent  of  anesthesia  after  blocking  the  lateral  femoral  cutaneous  and  femoral 

nerves. 


Crile  exposes  the  sciatic  nerve  and  blocks  it  by  endoneural  injection  (page  161). 
The  blocking  of  this  nerve  through  the  skin  is  difficult  and  unreliable.  The  nerve 
trunk  lies  deeply  seated  in  the  gluteal  region,  slightly  median  to  the  middle  of  the 
line  joining  the  trochanter  major,  and  the  tuberosity  of  the  ischium.  Laewen,  to 
whom  special  credit  is  due  for  his  thorough  investigations,  aims  to  palpate  the  nerve 
in  this  spot  in  lean  persons,  and  injects  from  two  points  of  entrance,  one  of  which  is 


OPERATIOXS   OX    THE   EXTia^MITIES 


375 


situated  2  cm.  outward  from  the  tul)ero.sity  of  the  ischium,  the  other  '.\  cm.  inward 
from  the  trochanter. 

Perthes  aims  to  reach  tiie  nerve  trunk  in  the  gluteal  fold.  Jassenetzki-Woino 
chooses  a  point  which  is  determined  by  the  intersection  of  a  horizontal  line  through 
the  greater  trochanter  and  a  vertical  line  through  the  outer  edge  of  the  tuberosity 
of  the  ischium.  It  is  immaterial  where  the  point  of  entrance  is  made,  but  what  is 
important,  and  should  not  be  omitted,  is  to  reach  the  nerve  trunk  wdth  the  point  of 
the  needle,  which  is  indicated  by  radiating,  paresthetic  sensations  felt  in  the  toes. 
The  importance  of  observing  these  paresthetic  sensations  has  been  shown  in  connec- 
tion with  the  brachial  plexus.  If  according  to  the  method  of  Laewen  a  4  per  cent, 
novocain-suprarenin  solution  is  injected  as  soon  as  the  paresthesia  occurs,  the  result 
is  almost  always  a  blocking  of  the  nerve  trunk.  Whether  or  not  this  blocking  is 
more  reliable  with  the  aid  of  a  Perthes  needle  the  future  must  decide. 


Figs.   198  and  199.— Anesthesia  of  the  great  toe.    (After  Oberst.) 

The  posterior  femoral  cutaneous  nerve  lies  beneath  the  gluteal  fold,  close  under  the 
fascia  in  the  middle  of  the  posterior  surface  of  the  thigh  and  is  located  here  w4th 
comparative  ease.  Laewen  attempted  to  locate  it  higher  up  where  it  is  deeply  situated 
close  behind  the  sciatic  nerve.  The  obturator  nerve,  according  to  Laewen,  cannot 
be  located  near  the  place  where  it  emerges;  therefore  he  aims  to  block  it  by  sub- 
cutaneous and  subfascial  semicircular  infiltration  on  the  inner  surface  of  the  thigh. ^ 

Laew^en  repeatedly  succeeded  in  making  the  w^hole  leg  anesthetic,  by  blocking 
all  these  nerves.  The  necessary  doses  of  novocain  (2.1  g.)  are  large  and  the  method 
is  too  complicated  to  be  of  any  practical  significance.  Laewen  himself  expressed 
this  opinion. 


'  Perthes  succeeded  in  puncturing  the  nerve  with  his  irritatitii: 
of  the  spine  of  the  pubes  at  the  obturator  foramen.    See  also  the  hitci 


le),  from  the  region 
.nd  Babitzki. 


376 


LOCAL  ANESTHESIA 


Anesthesia  of  the  Toe,  According  to  Oberst. — The  method  is  the  same  as  used  for 
the  fingers  (Figs.  198  and  199).  On  the  great  toe  two  points  of  entrance  are  marked 
on  the  edge  a  little  more  toward  the  extensor  side.  From  these  points  injections 
are  made  under  the  skin  of  the  flexor  side,  as  indicated  by  the  dotted  line.  On  account 
of  the  prominence  formed  by  the  extensor  tendons,  it  is  more  convenient  to  make  the 
injection  under  the  skin  of  the  extensor  side  from  a  third  point,  situated  in  the  middle 
of  the  extensor  side.  3  to  4  cc.  of  2  per  cent,  novocain-suprarenin  solution  are  neces- 
sary.   For  the  other  toes  the  points  are  marked  in  the  interdigital  spaces  as  in  Fig.  200. 


Fig.   200.— Disar 


of  the  great  t(jc.     Hallux  valgus  operatic 


Disarticulation  of  the  Great  Toe.  Hallux  Valgus  Operation  (Fig.  200).— There  are 
three  points  of  entrance  to  be  marked;  the  first  is  in  the  median  line  on  the  border 
of  the  foot,  the  second  on  the  back  of  the  foot  over  the  first  interosseous  space;  the 
third  in  the  first  interdigital  fold.  The  first  injection  is  made  into  the  interosseous 
space,  and  is  carried  out  just  as  in  the  hand.  The  needle  is  inserted  and  infiltration 
is  made  through  the  interosseous  space,  until  the  applied  finger  feels  the  point 
of  the  needle  under  the  skin  of  the  sole.  Then  follows  the  subcutaneous  injection 
from  points  1  and  3  in  the  direction  of  the  dotted  line:  40  to  50  cc.  of  0.5  per  cent, 
novocain-suprarenin  solution  will  be  necessary.  The  operator  should  wait  until  the 
whole  toe  becomes  insensitive.     Ligation  is  not  necessary  for  disarticulation. 

Disarticulation  of  the  Third  Toe.— Operations  on  the  Third  Metatarsal  Bone  (Fig. 
201). — Four  wheals  are  placed  as  in  the  corresponding  operation  on  the  hand;  two 
lie  on  the  extensor  side  of  the  interdigital  folds,  two  on  the  back  of  the  foot  over  the 
second  and  third  interosseous  spaces.  The  needle  is  pushed  forward  from  points 
1  and  2,  injection  being  made  into  the  spaces  between  the  bones  until  the  needle 


OPERATIOXS   OX    Till':   EXTREMITIES 


377 


is  felt  under  the  skin  of  the  sole  at  jx 
4  under  the  skin  of  the  sole  toward 
foot  toward  i)oints  1  and  2.  Fina 
points  1  and  2;  .")()  cc.  of  ()..")  per  cei 


int  (t.  'V\w\\  follow  injeetions  from  jxtints  ."I  and 
point  <i,  and  under  the  skin  of  the  back  of  the 
ly,  snlx'utaneous  injections  are  made  between 
t.  noxocain-suprarenin  solution  are  necessary. 


m 

Fig.  201. — Disarticulation  of  the  third  toe. 

Operations  on  the  Back  of  the  Foot. — The  technique  of  the  anesthesia  is  the  same 
as  for  the  back  of  the  hand.  There  is  nothing  to  add  to  that  which  has  already  been 
stated  on  page  o()2. 

Tenotomy  of  the  Tendo-Achillis  (Fig.  202). — A  point  of  entrance  is  marked  to  the 
right  and  left  of  the  tendo-Achillis,  and  the  field  of  operation  is  infiltrated  in  a  trough- 
like manner,  according  to  Fig.  31  (page  191).  In  adults  and  older  children  it  is 
possible  to  perform  operations  on  the  tendo-Achillis  under  local  anesthesia.  These 
cases  are,  of  course,  always  exceptional,  as  the  other  therapeutic  measures  associated 
with  tenotomy  usually  require  further  anesthesia. 

Anesthesia  of  the  Entire  Foot. — For  extensive  operations  on  the  bones  and  soft 
parts  of  the  foot  always  observe  the  following  directions:  Fi\e  nerves  pass  from 
the  calf  of  the  leg  to  the  foot,  the  tibial,  saphenous,  sural,  and  superficial  and 
deep  peroneal  (see  F'igs.  192  and  193).  Blocking  the  tibial  behind  the  internal 
malleolus  produces  anesthesia  of  the  region  designated  in  F'igs.  203  and  204,  and  the 


378 


LOCAL   ANESTHESIA 


Fig.  202.— Tenotomy  of  the  tendo  Achillis. 


FiGs.  203  to  208— \nf"5thcsi.i  of  foot  following  conduction  anesthesia.  Figs.  203  and  204,  tibial  is 
blocked  behind  the  inner  malleolus.  Fig  205,  subcutaneous  injection  of  a  semicircle  above  the  inner  malle- 
olus: Figs.  206  and  207,  subcutaneous  injection  of  a  semicircle  above  the  outer  malleolus;  Fig.  208,  injection 
of  the  deep  peroneal  nerve. 


OPERATIOXS   <)\    Till':   EXT  REM  IT  IKS 


379 


blocking  of  the  deop  poroneal  is  shown  in  Fit;-.  2()S.  IF  an  iinesthetic  is  suhciita- 
neoiisly  injected  in  a  transverse  strij)  above  the  internal  nialleokis,  the  terminal 
branches  of  the  saphenous  nerve  will  be  blocked,  and  anesthesia  of  the  skin  area, 
shown  in  Fig.  205  is  obtained.  In  the  same  manner  a  strip  injected  above  the  outer 
malleolus  will  block  the  superficial  peroneal  and  sural,  and  anesthesia  of  the  area 
shown  in  Figs.  206  and  207  is  obtainetl. 


Tibidlh  post. 
Fle.ior  digitorum 


3-section  of  the  leg  above  the  ankle-joint.     (After  Braun.)     The  arrow  indicates 
the  method  of  injecting  the  tibial  nerve. 


It  is  very  easy  to  block  the  tibial  at  the  designated  spot.  Fig.  209  shows  a  cross- 
section  through  the  low^er  leg  just  above  the  ankle.  The  arrows  indicate  the  direc- 
tion taken  by  the  needle  in  reaching  the  nerve  trunks.  The  point  of  entrance  lies 
high  up,  where  the  inner  malleolus  is  thickest,  about  1  c.c.  distant  from  the  tendo- 
Achillis.  From  this  point  the  needle  is  inserted  directly  forward  until  the  posterior 
surface  of  the  tibia  is  felt.  Continued  search  must  be  made  until  the  patient,  who 
has  been  previously  instructed,  announces  that  paresthesia  is  felt,  radiating  to  the 
toes.  If  blood  flows  from  the  needle,  it  must  be  drawn  back  a  little,  and  reinserted 
more  to  the  side.  As  soon  as  the  paresthesia  is  felt,  5  c.c.  of  2  per  cent,  novocain- 
suprarenin  solution  are  injected  and  after  a  few  minutes  the  blocking  of  the  nerves 
will  be  noted. 


380  LOCAL  ANESTHESIA 

The  method  is  as  follows:  several  points  of  entrance  are  marked — one  at  the  point 
mentioned,  behind  the  inner  malleolus;  the  others,  usually  four,  are  marked  at  the 
same  height  all  around  the  lower  leg.  The  tibialis  is  blocked  by  an  injection  of  5  c.c. 
of  2  per  cent,  novocain-suprarenin  solution  as  described  above,  and  the  subcutaneous 
cellular  tissue  of  the  lower  leg  is  then  infiltrated  from  the  other  points  of  entrance 
as  is  also  the  tissue  lying  between  the  tendons  and  the  anterior  surface  of  the  tibia. 
The  latter  is  done  in  order  to  block  the  deep  peroneal.  Finally  the  fat  which  lies 
behind  the  tendo-Achillis  is  infiltrated  with  50  to  75  c.c.  of  0.5  per  cent,  novocain- 
suprarenin  solution. 

This  excellent  method  is  used  in  performing  operations  on  the  sole  of  the  foot  and 
the  metatarsal  and  tarsal  bones.  We  have  performed  amputations  according  to  the 
methods  of  Lisfranc,  Chopart,  Pirogoff,  disarticulations  at  the  ankle-joint,  resections 
in  the  region  of  the  tarsus  and  operations  for  the  correction  of  club  foot  in  older 
children.  This  method,  which  is  naturally  contra-indicated  in  cases  of  phlegmon,  has 
never  failed  us.  For  amputation  it  is  not  necessary  to  ligate  the  extremity,  because 
the  arteries  bleed  so  little  under  the  influence  of  the  suprarenin. 

Operations  on  the  Leg. — It  is  necessary  to  thoroughly  inject  under  and  around  the 
field  of  operation  of  the  leg,  even  if  it  be  superficial  and  confined  to  the  skin  and  sub- 
cutaneous cellular  tissue.  A  simple  subcutaneous  circuminjection  is  unreliable.  The 
anastomotic  peroneal  nerve  and  the  saphenous  nerve  which  supply  the  skin  of  the  leg 
are  easily  blocked,  the  former  in  the  popliteal  space,  beside  the  head  of  the  fibula,  the 
latter  by  infiltrating  a  strip  of  the  subcutaneous  cellular  tissue  which  extends  laterally 
from  the  tuberosity  of  the  tibia  to  the  middle  of  the  calf  of  the  leg.  A  0.5  per 
cent,  novocain-suprarenin  solution  is  used.  This  blocking  has  little  practical  value 
because  the  blocking  of  the  third  nerve  supplying  the  tibia,  namely,  the  tibial,  in 
the  popliteal  space  is  unreliable  and  difficult,  and  the  blocking  of  the  two  first  named 
nerves  alone  only  renders  a  small  area  insensitive.  Bier's  venous  anesthesia  (page 
164)  is  suitable  for  complicated  aseptic  operations  and  amputations  of  the  leg. 

Operations  About  the  Knee. — For  anesthesia  of  a  prepatellar  bursa,  four  points 
of  entrance  must  be  marked,  situated  as  shown  in  Fig.  210.  A  subcutaneous 
injection  alone  in  the  direction  of  the  dotted  line  would  not  be  sufficient,  so 
before  making  this  injection  it  will  be  necessary  to  push  the  needle  forward  from 
each  point  of  entrance  and  infiltrate  in  various  directions  to  the  edge  of  the  patella; 
or,  if  this  is  not  possible  on  account  of  the  size  of  the  tumor,  the  capsule  of  the  knee- 
joint  must  be  infiltrated  from  the  side  and  the  quadriceps  from  above;  75  to  100  c.c. 
of  0.5  per  cent,  novocain-suprarenin  solution  will  be  necessary.  Extirpation  of  the 
bursa,  in  aseptic  or  slightly  infected  cases  never  requires  a  general  anesthetic.  The 
use  of  local  anesthesia,  however,  should  be  avoided  in  a  perforated  bursa  with  a 
phlegmonous  condition  of  the  surrounfling  parts. 


OPERATIOXS  OX   Till-:   EXTHKM  IT  I ES 


381 


Ganglia  in  the  Popliteal  Space. —(Janulia  should  always  l)e  e.\tiri)atc(l  under  local 
anesthesia.  The  tumor  must  be  carefully  circuniiiijected  with  u  0.-3  per  cent,  uovocain- 
suprarenin  sohition  from  four  points  of  entrance.  At  first  the  injection  should  he 
very  deep,  and  then  subcutaneous.  If  duriuii'  the  oi)eration  one  of  the  Large  nerve 
trunks  should  come  into  view,  it  must  be  i)lockcd  by  an  endoneural  injection  of  novo- 
cain-suprarenin  solution. 


Fig.   210. — Anesthe.sia  for  housemaid's  knee. 


Operations  on  the  Knee-joint. — Anesthesia  for  aspiration  of  the  knee-joint  is 
carried  out  according  to  the  rules  given  on  page  189.  The  synovial  membrane  is 
very  quickly  made  insensitive  by  filling  the  joint  with  a  0.5  per  cent.  no\'ocain- 
suprarenin  solution,  which  also  relieves  the  contractions  induced  by  the  pain.  For 
cases  of  erosion  of  the  joint  or  where  adhesions  exist  within  the  joint,  this  is  not  a 
suitable  method.  On  the  other  hand,  in  performing  aseptic  arthrotomies  of  the  knee- 
joint  for  movable  cartilages  and  for  meniscus  operations,  local  anesthesia  is  most 
suitable.  The  joint  is  filled  with  20  c.c.  of  0.5  per  cent,  novocain-suprarenin  solu- 
tion and  from  two  points  of  entrance  (Fig.  211,  1  and  2)  the  joint  capsule  and 
subcutaneous  cellular  tissue  are  infiltrated  in  the  line  of  incision  (according  to  Fig. 
27,  page  187)  with  the  same  solution.  The  operations  are  always  painless,  even  if 
it  is  necessary  to  open  the  joint  wide. 

For  many  years  the  author  has  sutured  fractures  of  the  patella  without  exce})tion 
under  local  anesthesia.  The  points  of  entrance  are  practically  the  same  as  for  prepa- 
tellar bursse  (Fig.  210)  only  the  lateral  points  lie  a  little  farther  back.  As  much  of  a 
0.5  per  cent,  novocain-suprarenin  solution  is  injected  into  the  joint  as  it  will  hold 
without  causing  too  much  pressure  and  the  fluid  is  distributed  by  gentle  flexion  and 


382 


LOCAL  ANESTHESIA 


extension  movements.  This  causes  a  part  of  the  fluid  to  flow  between  the  fractured 
parts  of  the  patefla,  producing  an  anesthetic  effect  similar  to  that  in  hoflow^  bones  (page 
381).  Finahy  the  joint  capsule  and  the  subcutaneous  cellular  tissue  are  infiltrated 
in  the  direction  of  the  dotted  line  (Fig.  211).  For  this  operation  100  to  150  c.c.  of 
0.5  per  cent,  novocain-suprarenin  solution  are  necessary.  In  most  cases  this  opera- 
tion is  painless.  Resections  of  the  knee-joint  are  better  performed  under  venous 
anesthesia. 


Fig.  211.— 1  and  2,  arthrotomy  of  the  knee-joint;  3  and  4,  resection  of  the  saphenc 


Supracondylar  Osteotomy  of  the  Femur.— The  operation  for  genu  valgum 
(unilateral  and  bilateral)  should  be  performed  under  local  anesthesia.  Four  points 
of  entrance  are  marked  as  indicated  in  Fig.  212.  From  these  points  the  needle 
is  directed  to  the  bone,  passing  in  front  of  and  behind  the  bone  during  the  pro- 
cess of  injection.  The  infiltration  is  only  made  immediately  around  the  bone 
at  the  place  where  the  osteotomy  is  to  be  performed.     The  muscles  need  not  be 


ni'l'Jh'ATIOXS   ON    Till':   F.XTRKMITIES 


3S3 


iiifiltratotl.  For  this  100  c.c.  of  0.5  per  cent,  iiovocain-siiprarciiin  arc  used.  After 
this  has  been  done,  two  more  points  are  marked  at  the  ends  of  the  incision  to  l)e  made, 
and  from  them  the  line  of  incision  is  infiltrated  to  the  bone  (Fig.  29,  page  189 j.  The 
bone  can  then  be  exposed  in  the  usual  manner  and  severed  partly  by  aid  of  the 
chisel  and  the  remainder  by  breaking.  The  patient  must  be  prepared  for  this  latter 
act,  so  that  he  will  not  be  frightened  by  the  cracking  of  the  bone. 


Fig.  212. — Supracondylar  osteotomy  of  the  femur. 


Operations  on  the  Soft  Parts  About  the  Temur.— Aseptic  fields  of  operation  of 
almost  any  size  can  be  rendered  insensitive  by  pyramidal,  trough-shaped,  or  similar 
forms  of  circuminjection,  but  the  simple  subcutaneous  circuminjection  may  fail  even 
in  very  superficial  operations  on  account  of  the  numerous  points  of  exit  of  the  nerves 
(Figs.  192  and  193). 

Operations  on  the  Saphenous  Vein.— If  only  a  narrow  anesthetized  zone  is  neces- 
sary, as  is  often  the  case  in  the  ligation  of  vessels  or  for  the  inducing  of  venous 
anesthesia,  then  the  infiltration  should  be  made  in  the  line  of  incision.  A  wheal 
should  mark  each  end  of  the  proposed  incision,  and  0.5  per  cent,  novocain-supra- 
renin  solution  should  be  injected  into  the  line  of  incision  under  and  beside  the  vein, 
and  the  points  of  entrance  should  be  joined  by  a  subcutaneously  injected  strip.  If 
a  portion  of  the  vein  is  to  be  resected  according  to  the  method  of  Trendelenburg,  it 


384 


LOCAL   ANESTHESIA 


will  be  necessary,  in  order  to  gain  a  larger  anesthetized  field,  to  make  a  rhombic  infil- 
tration at  first  under  and  around  the  vein,  and  then  a  subcutaneous  one.  Fig.  211 
illustrates  this  method  at  the  spot  where  varicose  veins  should  always  be  resected, 
that  is  at  the  upper  end  of  the  vein,  where  it  enters  the  femoral.  The  technique  of 
anesthesia  is  the  same  as  that  just  described. 


^-« 


Fig.  213.— Injection  foi 

Thiersch  grafts. 


Fig.   214. — Circuminjection  of  the  inguinal  region. 


For  the  removal  of  long  Thiersch  epithelial  grafts  it  is  advisable  to  infiltrate  the 
entire  outer  surface  of  the  thigh  subcutaneously  with  0.5  per  cent,  no^'ocain-supra- 
renin  solution.  For  this  purpose  a  number  of  points  of  entrance  are  marked  in  the 
order  shown  in  Fig.  213,  and  injection  of  0.5  per  cent,  novocain-suprarenin  solu- 
tion is  made  from  each  point  in  various  directions  and  an  even  distribution  of  the 
solution  into  the  subcutaneous  cellular  tissue  can  be  obtained  by  gentle  massage. 

The  extirpation  of  lymphomata  of  the  inguinal  and  femoral  regions  can  very  easily 
be  made  painless  by  circuminjecting  the  tumor  with  0.5  per  cent,  novocain-supra- 
renin solution  in  some  such  manner  as  indicated  in  Fig.  214.  The  needle  should  be 
inserted  from  all  sides,  pass  under  the  tumor,  and  should  penetrate  the  region  of 
the  fossa  ovalis  below  and  also  laterally  under  the  fascia  of  the  pectineus  muscle 
and  the  rectus  femoris  and  above  under  Poupart's  ligament.  For  the  curettement 
of  diseased  lymph  glands  the  same  method  is  necessary.  For  bilateral  removal 
of  all  the  fatty  tissues  with  the  glands,  in  the  groin,  use  local  anesthesia  and 
circuminject  in   the  manner  shown  in  Fig.  215.      It   is  also  necessary  to  make  a 


OPERATIOXS  OX   THE   EXTREMITIES 


3So 


subfascial   injection,  especially   under  the  fascia  of  the  external  ohlicjue  muscle  in 
the  region  of  the  skin  o\erlyin,u-   Poupart's  liuaincnt. 


Fig.  215.— ( 


The  diagram  illustrates  the  manner  in  which  a  circuminjection  around  the  root 
of  the  penis  for  penis  amputation  (page  330)  can  be  added.  For  such  extensive 
anesthesia  not  less  than  200  c.c.  of  0.5  per  cent,  novocain-suprarenin  solution 
will  be  required. 


INDEX, 


Abdominal  operations,  296 

median  incision  in,  301 
paravertebral  conduction  anesthesia  in, 
297 
sensation,  38,  296 

loss  of,  in  spinal  anesthesia,  40 
viscera,  abdominal  sensations  of,  38,  297 

sensibility  of,  38 
wall,  anesthesia  of,  297 

anterior,  innervation  of,  278 
innervation  of,  278 
sensibility  of,  36 
Abscess  of  lungs,  287 

subphrenic,  288,  291 
Absorption  of  active  substances,  66 
by  difference  in  pressure,  64 
of  oily  solutions,  65,  99,  129 
from  serous  cavities,  65 
from  subcutaneous  connective  tissue,  65 
vital  forces  in,  65,  129 
Accessory  nerve,  262 
Achilles,  tendon  of,  tenotomy  of,  377 
Actinien,  experiments  with  cocain  on,  SO 
Adonidin  (edalin),  127 
Adrenalin,  134 

novocain  and,  122 
Akoin,  dosage  of,  112 

injections  in  dentistry,  112 
gangrene  from,  109 
poisoning  from.  111 
solutions,  concentration  of,  110 
with  suprarenin,  140 
Alcohol  as  a  narcotic  anesthesia  of  mucous  mem- 
brane, 18,  24 
Alveolar  process,  operations  on,  253 
Alypin,  death  from,  120 
poisoning  from,  120 
in  rhinology,  120 
with  suprarenin,  141 
Alypin-suprarenin  tablets,  178 
Amaurosis,    transitory,    following   orbital   injec- 
tions, 213 
Ameba,  cocain  and,  84 

Amputation  after  endoneural  injections,  162 
anesthesia  in,  arterial,  166 

vein,  163 
of  penis,  330 
Amylen,  22,  46 

anesthesia  with,  45-54 
Amylnitrite  in  cocain  poisoning,  94,  95 


Anul  region,  operations  in,  340 
Analgesia,  40 
circular,  158 

of  finger,  15S 
Anemia,  effect  of,  on  general  and  local  poisoning, 
66,  130 

on  nerves,  43 
following  application  of  cocain,  80 

use  of  ethylchlorid  spray  as  an  aid  to 
anesthesia,  138 
of  suprarenin  as  an  aid  to  anes- 
thesia, 138 
with  suprarenin,  147 
Aneson,  freezing-point  of,  109 
Anesthesia  in  amputations,  163,  166 
with  amylene,  45-54 
by  anestol,  50 
by  anestyl,  50 
arterial,  73 

toxic  action  in,  167 
of  brachial  plexus,  349 
by  carbon  disulfide,  46 
central,  40 

of  cervical  nerves  of  neck,  267 
of  cheek,  236 
by  chemical  agents,  26,  36 
of  chin,  238 
by  chloroform,  45 
cocain,  oligemia  in,  80 
by  cold,  20,  45-54 
conduction,  40 

by  anemia,  41 

of  central  intercostal  nerves,  389 

by  diffusion,  73 

by  endoneural  injections,  161 

by  nerve  compression,  41 

parasacral,  320 

paravertebral,  279 

in  pelvis,  316 

perineural,  157 

sacral,  163 

technique  of,  40,  173,  180 
of  conjunctiva,  231 
by  cooling,  45-55 
of  cornea,  231 
of  cranium,  194 
of  cysts,  193 
by  dehydration,  61 
in  dislocations  of  extremities,  344 
duration  of,  68,  72,  82,  110 
with  ether,  45-54 
by  ethyl  bromide,  46 


Anesthesia  by  ethyl  chloride,  48 
with  ethyline  chloride,  45-54 
by  evaporation,  50 
of  exterior  nose,  236 
of  external  auditory  canal,  205 

ear,  206 
of  finger,  355 

of  floor  of  mouth,  262,  263 
of  fold  of  thigh,  307 
following  subcutaneous  injection  of  water, 

64 
of  foot,  376 
of  forearm,  366 

in  fractures  of  extremities,  344 
general,  local  anesthesia,  and  170 

technique  of,  171-193 

theories  of,  71 
of  hands,  356 
of  ileocecal  region,  302 
infiltration,  72,  73,  149,  181 

edema  in,  151 

technique  of,  178 
of  inflamed  tissues,  technique  of,  193 
instrumentarium  for,  technique  of,  171 
of  intercostal  nerves,  288 
of  knee-joint,  379 
by  koryl,  50 
in  laryngology,  275 
of  leg,  379 

of  line  of  incisions,  183-190 
local,  arterial  anesthesia  in,  168 

cataphoresis  and,  24,  148 

conduction  anesthesia,  151 

definition  of,  40 

ether  spray  in,  131 

ethyl  chloride  in,  131 

general  anesthesia  and,  170 

history  of,  17-26 

indications  for,  40,  170 

infiltration  anesthesia,  149 

influence  of,  on  surgery,  168 

instrumentarium  for,  171-180 

ligation  and,  159 

maximum  dosage  in,  value  of,  70 

narcotics  in,  71 

needles  used  in,  174 

properties  of,  70 

of  superficial  surfaces,  146 

syringe  for,  171 

tablets  in,  178 

technique  of,  171-193 

value  of,  168 

vein  anesthesia,  163 
of  lower  extremities,  370 
lumbar,  163 

of  mandibular  nerve,  219 
of  maxillary  nerve,  213 
of  membrana  tympani,  205 
by  metathyl,  50 
by  methyl  alcohol,  47 
of  mouth  for  minor  operations,  264 
of  mucous  membranes,  146 
of  mucous  membranes  with  novocain,  123 


Anesthesia  by  nerve  compression,  anemia  and, 
41,  45 

Oberst's,  158 

of  ophthalmic  nerve,  210 

in  ophthalmology,  230-235 

parasacral,  stretching  of  sphincter  ani  under, 
321 

of  penis,  330 

of  peritoneum,  298 

by  petroleum  ether,  46 

of  pharyngeal  tonsil,  267 

poisoning  of  central  nervous  system  from, 
70,  82,  86,  118 

of  prepuce,  328 

sacral,  163 

by  salt  solution,  62 

of  serous  membranes,  146 

of  shoulder,  369 

of  subcutaneous  connective  tissue,  82 

superficial,  of  mucous  membranes,  146 

of  synovial  membranes,  146 

terminal,  40,  72 

of  thigh,  370 

of  toes,  376 

of  tongue,  262,  263 

of  tonsillar  region,  264 

for  tonsillectomy,  264 

of  trigeminal  nerves,  210 

by  tumefaction,  63 

of  tympanic  cavity,  206 

of  upper  arm,  269 
Mp,  236 

vein,  73,  163 

venous,  toxic  action  in,  167 

of  wounds,  146 
Anesthesin,  116,  147 
Anesthesiphore,  atom  group,  70 

body,  114 
Anesthetic  effect  of  hgation,  41-44 

solutions,  irritation  cm-ve  of,  59 

power  of  active  substances,  66 
Anesthetica  dolorosa,  63,  67 
Anesthetics,  absorption  of,  66 

action  of,  on  venous  system,  71 

connection  of  benzol  group  with,  70 

diffusion  of,  68,  73 

through  skin  of  frog,  69 

properties  of,  66 

use  of,  66 
Anesthetization  of  ligaments,  33 
Anesthetizing  of  lower  jaw,  220,  259 

of  upi>ci-  jaw,  21."),  257 
Anestol,  aiicsilicsi.-i  l>y,  50 
Anestyl,  anesthesia  Ijy,  50 

Anikosmotic  solutions,  effect  of,  on  sensation,  58 
Anococcygeal  nerve,  316 
Antebrachial  fractures,  345 
Antip>Tin,  addition  of,  to  cocain,  94,  127 

anesthesia  in  laryngology,  127 
Anus,  operations  on,  340 

preternaturaUs,  301 

sensation  in,  34 
Appendix,  operations  on,  302 


389 


Ai)poiulix,  sensations  in,  o7 

Ardent uin  nitricum  with  (utlu)t'oriu,  114 

Ann,  innervation  of,  847 

..pnaticnis  on,  348 

npiH-r,  anesthesia  of,  3()9 
Arleniesia,  iM 
Arterial  anesthesia,  73 
Arieiies  of  neck,  ligation  of,  271 
Artln-otoniy  ot  elhow-joint,  368 

of  kncH^-joint,  381 
Atheroma,  extii'pation  of,  196 
Auditory  canal,  external,  anesthesia  of,  205 
Auricular  nerve,  great,  142,  204,  267 
Aurieulot(>nii)oral  nerve,  204 
Axilla,  innervation  of,  279,  293,  294 

operations  in,  279 
Axillar}'  nerve,  354 

B 

Basedow's  disease,  hgation  of  inferior  thyi'oid 

artery  in,  272 
Benzol  group,  connection  of,  with  anesthesia,  70 
Benzolpseudotropein,  100 
/3-eucain,  concentration  of,  105 

freezing-point  of,  105 

poisoning  from,  106 
Bile  passages,  operations  on,  301 
Bladder,  innervation  of,  323 

operations  on,  323 

sensations  in,  323 
Bloodvessels,  contraction  of,  from  cocain,  80 
Boiling  point  for  chemicals  used  for  freezing  the 

tissues,  46 
Bone   encasing  injection  of,  192 

sensations  of,  32 
Brachial  plexus,  294,  344 

anesthesia  of,  349 
Brain,  operations  on,  195 

pain  sense  of,  28,  35 

puncture  of,  195 

temporal  region  of,  operations  in,  201 
Braun's    injections    into    foramen    ovale,    tech- 
nique of,  225 
Breast,  operations  on,  293 

tumors  of,  benign,  294 
malignant,  294 
Buccinator  nerve,  257 
Bm-cin,  126 
Bursa  olecrani,  368 

prepatellar,  381 


Cannabis  indica,  18,  21 

Carbolic  acid,  126 

diffusion  of,  through  epidermis  in  com- 
bination with  cocain,  68 

Cai-bon  disullidi',  anesthesia  by,  46 

Carbonic  ari.l,  _':;,  _' 1 

Carcinoma  of  aitifieial  rectum,  343 

of  floor  of  mouth,  radical  operation  for,  265 
of  tongue,  radical  operation  for,  265 

Carotid  artery,  common,  ligation  of,  271 


Carotid  artery,  exieinal,  ligation  of,  271 
Cataphoresis  for  anesthesia  of  ear  drum,  203 

of  cutis,  148 

in  dentistry,  148 

local  anesthesia  ami,  24,  148 
Cavities,  anesthetizing  of,  with  cocain,  93,  94 
Cecosl,..nv,  :;(»! 
CerelH.llum,  exposure  of,  203 

sensations  of,  35 
Cervical  nerve,  L'Cu 

of  neck,  .anesthesia  of,  267 
Cheek,  anesthesia  of,  •_':>() 

region  of,  iiwasion  of,  238 
Chest   wall,  iiinervalion  of,  278 
ChikI,  local  .anesllK'Si.a  in,  197 
Chin,  anesthesi.a  of,  238 
Chloi-olurni,  anesthesia  by,  45 
Ciliarv  nerve,  •_'13 
Cinaiiar  ;iii,al-esia,  158 
Cir(ailation,  disturbances  of,  from  cold,  47 
Clavicle,  operations  on,  370 
Clitoris,  (l,,rs,al  nerve  of,  317 
Club-foot,  operations  on,  379 
Cocain,  absorption  of,  66 

action  of,  on  nerves,  79,  91 

addition  of  antipyi'in  to,  94,  127 

alkaline  solution  of,  98 

ameba  and,  84 

anesthesia,  cold  in,  92,  98,  132 
in  dentistrv,  76 


i(li( 


"I 

of  pe 


of. 


hthah 


for,  95 


ology,  230 


anesthetizing  of  cavities  with,  93,  94 
cold  and,  132 
concentration  of,  77,  90 
contraction  of  bloodvessels  from,  80 
determination  of  freezing  point  of,  82 
diffusion  of,  68 
disintegration  of,  in  body,  81 
dosage  of,  124 

fatal,  88 

maximum,  91 
edema  after  injection  of,  68 
effect  of,  on  nerves,  80 
ethyl  chloriil  and,  98 
glandular  seiact  ion  and,  SO 
hydrocliloiaie,  '.)s 
idiosvnciMsies  K.w.ard,  90,  92 


mject  I 


from,  96 


al,  90 


in  laryngolo,  _ 
lepidoptera  and,  si 
leukocytes  and,  8  1 
nitroglycerin  and,  94 
paralysis  of  sense  of  si 

taste  by,  84 
plants  and,  84 


390 


Cocain  poisoning,  78 

amylnitrate  in,  94,  95 
convulsions  in,  86 
death  from,  78,  79 
general,  85 

irritation  in,  88 
history  of,  75 
in  laryngology,  78 
local,  79 

of  mucous  membranes,  78 
paralysis  in,  86 
prevention  of,  91,  96 
psychical  diseases  in,  86 
symptoms  in,  85,  86 
in  serous  cavities,  78 
of  stomach,  79 
treatment  of,  narcotics  in,  95 
preparation  of,  96 
properties  of,  74 

chemical,  70,  74 
physical,  74 
resorcin  and,  94 
in  rhinology,  76 
solutions  of,  dilute,  61 

freezing  point  of,  82,  96 
sterilization  of,  97 
sterilization  of,  96 

according  to  Schleich,  156 
temperature  sense  and,  S3 
Cocainization  of  mucous  membrane  of  genitalia, 

76 
Cocainum  benzoicum,  98 
hydrobromicum,  98 
muriaticum,  98 
nitricum,  89 
phenylicum,  98 
salicylicum,  98 
Coccygeal  plexus,  315,  318 
Codeine,  edema  and,  68 
Cold,  anesthesia  by,  20,  45-54 
cocain  and,  132 

disturbances  of  circulation  fi-om,  47 
effect  of,  on  nerves,  47 
indications  for  use  of,  51 
Collapse,  treatment  of,  suprarenin  in,  145 
Colporrhaphy,  333,  338 
Compression  of  nerves,  19,  20 

diminution  of  pain  from,  19,  41 
Conduction  anesthesia,  40 
parasacral,  320 
paravertebral,  279 
Conjunctiva,  anesthesia  of,  231 
Connective  tissue,  perineural  injections  of,  160 
Convallarin,  127 

Convulsions  in  cocain  poisoning,  86 
Cooling,  anesthesia  by,  45-55 
Cornea,  anesthesia  of,  231 
Cranium,  anesthesia  of,  194 

atheromata  of,  extirpation  of,  196 

brain  puncture,  195 

fracture  of,  treatment  of,  196 

innervation  of,  194 

rodent  ulcer  of,  extirpation  of,  197 


Cranium,  soft  parts  of,  injury  to,  196 
Cutaneous  antibrachial  nerve,  366 
lateral  femoral  nerve,  370,  373 
Cutis,  cataphoresis  of,  148 
Cysts,  anesthesia  of,  193 


Dehydration,  anesthesia  by,  61 
Dentistry,  akoin  injections  in,  112 

anesthesia  in,  general,  261 
local,  168,  253 

history  of,  253 

cataphoresis  in,  148 

cocain  anesthesia  in,  76 
cold  and,  132 

cocain-phenylat  solutions  in,  79 

nirvanin  in,  115 

novocain  in,  121 

tropacocain  in,  103 
Diaphragm,  sensations  of,  36 
Diminution  of  pain  from  compression  of  nerves, 

19,  41 
Dionin,  127 
Disarticulation  of  big  toe,  376 

of  elbow-joint,  368 

of  foot,  379 

of  shoulder-joint,  369 
Disinfection  of  operative  field,  181 
Dislocation  of  fingers,  357 

of  humerus,  345,  347 

of  obturator,  346 

of  olecranon,  345 

of  sciatic,  346 

of  tibia,  346 
Dorsal  nerve  of  clitoris,  317 

of  penis,  316 
Drum,  anesthesia  of,  by  cataphoresis,  205 

innervation  of,  194,  204 
Dura,  pain  sense  of,  35,  194,  199 

sensations  of,  35 


Ear,  external,  anesthesia  of,  206 
I  muscles  of,  anesthesia  of,  206 

!  Ecgonin,  75,  113 
i  Edema,  codeine  and,  68 

following  injections  of  peronin,  68,  127 

in  infiltration  anesthesia,  151 

after  injection  of  cocain,  68 
of  tropacocain,  68,  101 

in  local  poisoning,  66 

morphin  and,  68 

pain  sense  in,  30 

peronin  and,  68 

tropacocain  and,  102 
Elbow-joint,  arthrotomy  of,  368 

disarticulation  of,  368 

operations  on,  368 

resection  of,  368 


J 


391 


I'Mectricity  in  local  anesthesia,  23,  77,  10 1 
Kinl>()li,  paralysis  after,  44 
Enij^hv.spnia,  rib  resection  in,  284 
of  thorax,  2S7 

Femoral  hernia,  operations  for,  310 

nerve,  161,  272 
Femm-,  supracondylar  ost.-otcmiy  of,  382 

Einpyenui   of   antrum    of    Hif>;hnioro,    operative 
treatment  of,  246 

Fiuorr,   .•M,rsll„.M:,    nC:\r>.>     \\ 

thoracotoinv  u'n;  285 

Emlerniatic  iiilil'tral  ion,  183 

Endoneural  injeclions,  161 

amputations  after,  162 
couchiction  anesthesia  bv.  161 

Enucleation  ..f  .■yc-hall.  233 

compression  of,  elTect  of,  on  nerves,  43 
dislocation  of,  357 
phlegmon  of,  357 
Fistula  ani,  opcrati.ins  for.  312 

intestiii:il,   .,pci;ilion.  loi',   302 
urellii-;il,  opri-.iiioi,^  r,,r,  .V.iO 

ICpicyst 

Epiuephrin,  135 

Epirenin,  135 

Erythrophlein,  127 

Erythroxylin,  75 

Esophagus,  sensations  of,  34,  267 

Ether,  anesthesia  with,  45-54 

as  an  anesthetic,  22,  24,  45,  48,  53,  66,  131 

spray,  effect  of,  on  deeper  structures,  53 
in  local  anesthesia,  131 
Richardson's,  45 
Ethmoidal  nerve,  210,  216,  240 
Ethyl  bromid,  46 

anesthesia  by,  46 
Ethyl  chloride,  anesthesia  by,  48 
cocain  and,  98 
in  local  anesthesia,  131 
spray  in  anesthesia,  182 
in  dentistry,  255 
Ethyl  cocain  spray  in  dentistry,  98 
Ethyline  chloride,  anesthesia  with,  45-54 
Eucain,  a-eucain,  /3-eucain  with  suprarenin,  103 

dosage  of,  107 
Evaporation,  anesthesia  by,  50 
Excision  of  Gasserian  ganglion,  302 
Exenteratic  bulbi  or  bites,  232 
Exenteration  of  eye-ball,  233 

of  orbit,  232 
Extirpation  of  atheroma,  196 

of  Gasserian  ganglion,  202 

of  lymph  glands  of  neck,  269 

of  rectum,  343 

of  rodent  ulcer,  197 

of  uterus,  334,  338,  339 

of  vagina,  333 
Extremities,  fractures  of,  anesthesia  in,  344 

lower,  anesthesia  of,  370 
Eye,  anesthesia  of,  by  instillation,  231 

operations  on,  230 
Eye-ball,  enucleation  of,  233 
exenteration  of,  233 
Ej'e-lids,  operations  on,  235 


Face,  plastic  operations  on,  239 

soft  parts  of,  innervation  of,  255 
operations  on,  235 
Fallopian  tubes,  sensation  of,  39 
Fascia,  sensations  of,  31 


Foerster's  operatiuu,  2s  1 
Foot,  anesthesia  of,  376 

back  of,  operations  on,  377 
disarticulation  of,  379 
operations  on,  376 
Foramen,  infra-orbital,  213 
ovale,  injections  into,  225 

technique  of,  Braun's,  225 
Haertel's,  226 
Offerhan's,  224 
Ostwalt's,  226 
Schloesser's,  226 
rotundum,  injections  at,  216 
Forearm,  anesthesia  of,  366 

phlegmon  of,  369 
Forehead,  operations  on,  194 
Fork-shaped  freezing  apparatus,  49 
Fractures,  antebrachial,  345 

of  cranium,  treatment  of,  196 
of  radius.  345 
of  skull,  196 

supracondylar,  of  humerus,  345 
of  tibia,  345 
Freezing  apparatus,  fork-shaped,  49 
gangrene  from,  47,  50 
point  of  aneson,  109 
of  blood,  57 
of  /3-eucain,  105 
of  cocain  solutions,  82,  96 

Schleich's,  151 
of  tropacocain,  101 

of    watery    solutions    with    anesthetic 
properties,  59 
Frog-skin,  diffusion  of  active  substances  through, 

69 
Frontal  nerve,  210,  212 

sinuses,    mucous   membrane   in,    sensations 
of,  34 
operations  on,  244 


Gall-bladder,  sensations  in,  38 
Ganglion,  cervicale  uteri,  315 
Gasserian,  excision  of,  202 
extirpation  of,  202 
puncture  of,  226 
Gangrene  from  akoin  injections,  109 
from  cocain  injections,  96 
from  freezing,  47,  50 


392 


Gangrene  from  nerve  compression,  44 

from  stovain  injections,  117 

from  suprarenin,  145 
Gasserian  ganglion,  excision  of,  202 
extirpation  of,  202 
puncture  of,  226 
Gastro-enterostomy,  300 
Gastrostomy,  299 

Gelatin  as  an  aid  to  anesthetic  substances,  129 
General  cocain  poisoning,  85 
Genitalia,   mucous  membrane  of,   cocainization 

of,  76 
Genitofemoral  nerve,  306 
Genu  valgum,  operations  for,  382 
Glandular  secretion,  cocain  and,  80 
Gleditschin,  126 

Glossopharyngeal  nerve,  195,  204,  210 
Guaiacol,  127 


Haertel's  injections  into  foramen  ovale,  tech- 
nique of,  226 
Hallux  valgus,  operations  for,  376 
Hands,  anesthesia  of,  356 

phlegmon  of,  362 
Hare-lip,  operations  for,  237 
Head,  innervation  of,  194 

operations  on,  194 
Hearing,  organs  of,  operations  on,  204 
Heart,  operations  on,  287 
Helleborin,  127 
Hemlock,  17 

Hemorrhoids,  operations  for,  340 
Henbane,  17,  21 
Hernia,  303-314 

femoral,  operations  for,  310 

inguinal,  operations  for,  306 

irreducible,  operations  for,  310 

of  linea  alba,  operations  for,  305 

postoperative,  operations  for,  305 

reducible,  operations  for,  307 

strangulated,  operations  for,  310 

umbilical,  operations  for,  305 
Highmore,  antrum  of,  empyema  of,  246 
operative  treatment  of,  246 
sensation  of,  34,  215 
Holocain,  70,  108 

suprarenin  and,  141 
Homorenon,  136 
Humerus,  dislocation  of,  345,  347 

operations  on,  369 

supracondylar  fractures  of,  345 
Hydi-ocarbons,  danger  of  fire  with,  51 
Hydrocele,  sac  of,  328 
Hygroma  of  popliteal  space,  381 

prepatellar,  379 
Hyoscyamus,  17,  21 
Hyperalgesia,  29 

Hyperemia  in  local  poisoning,  65,  66 
Hyperosmotic  solutions,  56,  64 

injection  of,  dehydration  after,  60 
physiological  action  of,  60 


Hypertonic  solutions,  64 
Hj^osmotic  solutions,  56,  64 
Hypospadias,  330 

operations  for,  330 
Hypotonic  solutions,  56,  64 


Ileocecal  region,  anesthesia  of,  302 

operations  on,  301 
IHo-inguinal  nerve,  278,  282,  306,  309 
Incisions,  line  of,  anesthesia  of,  183-190 

preparation  of,  technique  of,  183 
Indications  for  cocain  anesthesia,  95 
Inferior  alveolar  nerve,  158,  161,  219,  256,  259 

hemorrhoidal  nerve,  316 

thyroid   artery,    Ugation   of,    in   Basedow's 
disease,  272 
Infiltration  anesthesia,  72,  73,  149,  181 
endermatic,  183 
indirect,  73,  149 
technique  of,  181 
Infra-orbital  foramen,  213 

nerve,  158,  213,  256 
Infratemporal  nerve,  235 
Inguinal  hernia,  operation  for,  306 

region,  innervation  of,  306 
tumors  of,  384 
Innervation  of  abdominal  wall,  278 

of  accessory  sinuses,  240 

of  arm,  347 

of  axilla,  279,  293,  294 

of  bladder,  323 

of  cavities  of  nose,  240 

of  chest  wall,  278 

of  cranium,  194 

of  extremities,  348,  370 

of  floor  of  mouth,  262 

of  hard  palate,  256 

of  head,  194 

of  inguinal  region,  306 

of  leg,  371 

of  lower  extremities,  370 

of  neck,  267 

of  orbit,  232 

of  organs  of  hearing,  204 

of  palate,  256 

of  rectum,  34,  315 

of  roof  of  skull,  194 

of  sexual  organs,  315 

of  soft  parts  of  face,  255 

of  teeth,  215,  256 

of  thigh,  306 

of  thorax,  287 

of  tongue,  262 

of  upper  extremities,  348 
Instrumentarium  for  local  anesthesia,  171-180 
Insulated  needle,  161 
Intercostal  nerves,  161,  278,  288 
anesthesia  of,  288 
central  conduction  of,  288-295 
anesthesia  of,  389 


393 


Intestinal  fistiil:r,  operations  for,  302 
Jiucsiinrs,  M'usation  of,  38 
Jiiirn-arli  rial  injootioiis  of  COCain,  90 
lntra\-cn(uis  injections  of  cocain,  90 
Inli-nitns  vaui.m'.  :;:;.■) 
IrnMluril.le  hri-nia.  operations  for,  310 
Iseluatie  n.Tve,  IGl,  374 
IsoMiinii,'  M.lutions,  56 
l.sotoiue  .-oliitions,  56,  Gl 


Jaw,  lower,  anesthetizing  of,  220,  259 
operations  on,  252 
operations  on,  246 
upper,  anesthetizing  of,  215,  257 
resection  of,  249 
Joint  capsule,  sensation  of,  33 
Joint-mice  in  knee,  381 
Joints,  injection  into,  345 


Kelexe,  98 

Ividney,  operations  on,  321 

sensation  of,  36,  39 
Ivillian's  operation,  244 
Knee-joint,  anesthesia  of,  379 

joint  artlirotomy  of,  381 

joint -niici.'  in.  :;sl 

meniscns  operations,  381 

puncture  of,  381 

vein  anesthesia  in,  resection  of,  382 

operations  on,  379 
Koryl,  50 

anesthesia  by,  50 
Ivrause's  flap,  369 
Kroenlein's  operation,  234 


Labia,  operations  on,  334 
Labial  nerve,  posterior,  317 
Lacrimal  nerve,  210,  212 
Lammectomy,  283,  284 
LarjTigectomy,  276 
LarjTigology,  anesthesia  in,  275 
antipyrin,  127 

cocain  in,  76 

poisoning  in,  78 

concentration  of  cocain  solutions  in,  95 

suprarenin  in,  137,  139,  142,  143 
LarjTigo-rhinolog}',  cocain  anesthesia  in,  76 
Lai-jTigotomy,  276 
Larynx,  operations  on,  276 

sensations  of,  267 
Leg,  anesthesia  of,  379 

innervation  of,  371 

operations  on,  370 

vein  anesthesia  in,  379 


Lepi.loi.ter:, 
Lcukoeyte-. 
Ligaments. 
Ligation,  ai 

of  :i 

of  ( 


an,l,  84 

-^  of,  after  cocain,  80 
I /.it  ion  of,  33 
etteet  of,  41-44 
•••k,  271 
.till  artery,  271 


of  external  carotid  arterj',  271 

of  extremities,  41 

of  inferior  thyroid  artery,  271 

in  Basedow's  disease,  272 

local  anestliesi;,  and,  159 

poisoninti  ami,  i:i() 

of  superior  thyroid  artery,  271 
Linea  alba,  hernia  in,  306 

operations  for,  305 
Lingual  nerve,  161,  219,  257,  262 
Lip,  lower,  operations  on,  238 

upper,  anesthesia  of,  236 
operations  on,  236 
Lipoma  of  shoulder,  369 
Liver,  operations  on,  301 

sensations  of,  31,  39 
Local  anesthesia.    See  Anesthesia,  local. 

cocain  poisoning,  79 
Lower  extremities,  innervation  of,  370 
Lumbar  anesthesia,  163 

with  /3-eucain,  108 

nerves,  278 
Lumbo-inguinal  nerve,  307 
Lungs,  abscesses  of,  287 

sensations  of,  39 
Lymph  glands  of  neck,  extirpation  of,  269 
Lymphatic  glands,  removal  of,  from  neck,  269 


M 

Mamm.e,  operations  on,  293 
Mandibular  nerve,  219 

anesthesia  of,  219 
Mandrake  root,  17,  21 
Mastoid  operation,  206 

proce-ss,  chiseling  of,  206 

operations  on,  209 
Maxillary  nerve,  213,  241,  262 

anesthesia  of,  213 
Median  nerve,  159,  160,  365 
Membrana  tympani,  anesthesia  of,  205 
Memphis,  stone  of,  18 
Meniscus,  operations  on,  381 
Mental  nerve,  222,  257 
Mesentery,  sensations  of,  36,  37 
Metathyl,  anesthesia  by,  50 
Methvl  alcohol,   16 

^       aiH-ilM-i:i  by,  47 
Methyl  ehlomlc,  t  hciinoisolator  for,  50 
Milk  sugar,  deteiinination  of  absorption  of,  131 
IMorphin,  edema  after  injections  of,  68 

scopolamin,  170,  171 
Mouth,  anesthesia  of,  for  minor  operations,  264 
floor  of,  anesthesia  of,  262,  263 

carcinoma  of,  radical  operation  for,  265 

innervation  of,  262 


394 


Mouth,  floor  of,  operations  on,  262,  264 

sensations  of,  262 
Moxa,  21 

Mucous  membranes,  anesthesia  of,  146 
with  novocain,  123 
superficial,  146 
cocain  poisoning  of,  78 
sensations  of,  34 
Musculocutaneous  nerve,  379 


N 

Narcotics  in  ancient  times,  17,  18 

in  local  anesthesia,  71 

in  treatment  of  cocain  poisoning,  95 
Nasal  cavities,  operations  on,  240 
Nasopalatine  nerve,  216 
Nasophar3Tigeal  fibroma,  261 
Neck,  arteries  of,  ligation  of,  271 

cervical  nerves  of,  anesthesia  of,  267 

innervation  of,  267 

lymph  glands  of,  extu-pation  of,  269 

operations  on,  267 
Necrosis  from  local  poisoning,  65,  66 

from  tumefaction,  60 
Needle,  insertion  of,  175 

insulated,  161 

puncture  for  formation  of  wheals,  183 

used  in  local  anesthesia,  174 
Nerve  or  Nerves,  accessory,  262 

action  of  cocain  on,  79,  91 

anococcygeal,  316 

am-icuiotemporal,  204 

axillary,  354 

buccinator,  257 

cervical,  267 

ciliary,  213 

compression,  conduction  anesthesia  by,  41 
gangrene  from,  44 

cutaneous  antibrachial,  366 
femoral,  lateral,  370,  373 

posterior,  315,  336,  356,  375 

diminution  of  pain  from  compression  of,  19, 41 

dorsal,  of  cUtoris,  317 
of  penis,  316 

effect  of  cocain  on,  80 
of  cold  on,  47 

ethmoidal,  210,  216,  240 

femoral,  161,  272 

frontal,  210,  212 

genitofemoral,  306 

glossopharyngeal,  195,  204,  210 

great  auricular,  142,  204,  267 

ihohypogastric,  378 

ilio-inguinal,  278,  282,  306,  309 

inferior  alveolar,  158,  161,  219,  256,  259 
hemorrhoidal,  316 

infra-orbital,  158,  213,  256 

infratemporal,  235 

intercostal,  161,  278,  288 
anesthesia  of,  288 
central  conduction  of,  288-295 


Nerve  or  Nerves,  ischiadic,  161,  374 

labial,  posterior,  317 

lacrimal,  210,  212 

Ungual,  161,  219,  257,  262 

lumbar,  278 

lumbo-inguinal,  307 

mandibular,  219 

anesthesia  of,  219 

maxillary,  213,  241,  262 
anesthesia  of,  213 

median,  159,  160,  365 

mental,  222,  257 

musculocutaneous,  379 

nasociUary,  211,  212 

nasopalatine,  216 

obturator,  375 

occipital,  161,  194,  204 

olfactory,  240 

ophthalmic,  210 

anesthesia  of,  210 

optic,  80,  213 

palatine,  215,  256 

pelvic,  315,  318,  331 

peroneal,  deep,  378,  379 
external,  379 

physical  effect  of  cooling  upon,  47 

pudic,  315,  316,  331,  333 

radial,  159,  160 

recm-rent,  275 

saphenous,  378,  379 

sciatic,  118,  161,  374 

spermatic,  306 

spinal,  204 

superficial  cervical,  194,  267 

superior  alveolar,  213,  256,  258 

supraclavicular,  267,  279,  292 

supra-orbital,  161 

sympathetic,  28,  278,  280 

thoracic,  278 

tibial,  378,  379 

trigeminal,  194,  210 
anesthesia  of,  210 

trunks,  preparation  of,  technique  of,  192 

ulnar,  158,  160,  363 

vagus,  194,  204,  262,  267 

zygomatic,  232 
Nervous  system,  action  of  anesthetics  on,  71 

central,  poisoning  of,  from  anesthesia, 
70,  82,  86,  118 
Nirvanin  in  dentistry,  115 

for  perineural  injections,  115,  160 

poisoning  from,  115 
Nitroglycerin,  cocain  and,  94 
Nose,  bony  parts  of,  operations  on,  240 

exterior  of,  anesthesia  of,  236 

innervation  of  cavities  of,  240 

outer,  operations  on,  236 
plastic,  239 
Novocain,  action  of  suprarenin  with,  123,  135, 175 

adi-enahn  and,  122 

anesthesia  of  mucous  membrane  with,  123 

borate,  124 

concentration  of,  122 


J 


395 


Novocain,  death  from,  12.3 
in  dentistry,  IL'I 
dosatio  of,  ISO 

luaxiinmn,   124 
eXlHTlllKMllS  will),   122 
ineltiim  point  of,  121 
phosphate,  124 

physiological  eoiicentnitioii  of, 
poisoning  from,  124 

sj-mptoms  of,  124 
sterilization  of,  178 
-suprarenin  tablets,  122,  179 


Oberst's  anesthesia,  158 
Obturator  nerve,  375 
Occipital  nerve,  161,  194,  204 
ffidema.    See  Edema, 
ffisophagus.    See  Esophagus. 
Offerhaus'  injections  into  foramen  ovale,   tech- 
nique of,  224 
Olecrani  bursa,  368 
Olecranon,  dislocation  of,  345 

operations  on,  368 
Olfactoiy  nerve,  240 
Oligemia  in  cocain  anesthesia,  80 
Omentum,  sensations  of,  36 
Operation  or  Operations,  on  alveolar  process,  253 

in  anal  region,  340 

on  appendix,  302 

on  arm,  348 

in  axilla,  279 

on  bile  passages,  301 

on  bladder,  323 

on  bony  parts  of  nose,  240 

on  brain,  195 

on  breast,  293 

on  clavicle,  370 

on  club-foot,  379 

on  elbow-joint,  368 

on  eye,  230 

on  eye-hds,  235 

on  face,  plastic,  239 

for  femoral  hernia,  310 

field  of,  preparation  of,  teclinique  of,  190 

on  fistula  ani,  342 

on  floor  of  mouth,  262,  264 

Foerster's,  284 

on  foot,  376 

on  forehead,  194 

on  frontal  sinuses,  244 

for  genu  valgum,  382 

for  hallux  valgus,  376 

for  hare-lip,  237 

on  head,  194 

on  heart:,  287 

for  hemorrhoids,  340 

for  hernia,  303 

of  linea  alba,  305 

on  humerus,  369 

on  iliocecal  region,  301 


Operation  or  Operations,  for  hypospadias,  33C 

for  inguinal  hernia,  30(5 

for  int(^stinal  fistula^  302 

for  irreducible  hernia,  310 

on  jaws,  246 

on  kidney,  321 

Killian's,  244 

on  knee,  379 

KroenUiin's,  234 

on  labia,  334 

on  larynx,  276 

on  leg,  370 

on  liver,  301 

on  lower  jaw,  252 
teeth,  259 

on  mammae,  293 

mastoid,  206 
process,  209 

on  meniscus,  381 

on  nasal  cavities,  240 

on  neck,  207 

on  olecranon,  'M\S 

on  orbit,  2.')() 

on  organs  of  hearing,  204 

on  palate,  261 

on  pericardium,  287 

on  pcriproctitic  abscesses,  343 

for  jihnnosis,  :;2S 

for  ]  lost  operative  hernia,  305 

for  prolapse  of  uterus,  321,  336 

for  retlucible  hernia,  307 

on  scalp,  194 

on  scrotum,  325,  333 

on  shoulder-joint,  369 

on  skull,  197 

on  spinal  column,  278 

for  strangulated  hernia,  310 

on  tear  sac,  235 

on  thorax,  278 

tongue,  2()2,  263 

on  tonsils.  202 

for  umbilical  hernia,  305 

on  upper  teeth,  257 

on  urethra,  330-332 

for  urethral  fistulse,  330 

on  uterus,  338,  339 

on  vagina,  333-335 
Ophthalmic  nerve,  210 

anesthesia  of,  210 
Ophthabnology,  anesthesia  in,  230-235 

cocain,  230 
Opium,  17,  21 
Optic  nerve,  80,  213 
Orbit,  exenteration  of,  232 

injections  into,  211,  244 

innervation  of,  232 

operations  on,  230 
Orbital  injections,  amaurosis  following,  213 
Organs  of  hearing,  innervation  of,  204 
Orthoform,  113,  147 

new,  115 

with  argent  urn  nitricuni,  114 
Osmosis,  55,  61 


396 


Osmosis,  history  of,  61 

by  salt  solution,  59 
Osteotomy,  supracondylar,  of  femur,  382 
Ostwalt's  injections  into  foramen  ovale,   tech- 
nique of,  266 
Ouabain,  127 
Ovaries,  sensation  of,  39 


Pain,  27 

conduction  tracts  for,  38 
localization  of,  28 
sensation  in  various  organs,  30 
sense,  28 

of  brain,  28,  35 
physiological,  27 
psychological,  27 
transmitting  apparatus,  38 
tumefaction,  59 
Palate,  anesthesia  of,  214 
hard,  innervation  of,  256 
innervation  of,  256 
operations  on,  261 
Palatine  nerve,  215,  256 
Paralysis,  cocain  poisoning  and,  87 

curve,  anesthetic  solutions  and,  59 
emboli,  44 

following  hgation,  41,  43,  44 
local  poisoning  and,  65 
of  sense  of  sincU  from  cocain,  84 
of  taste  hy  ('ocain,  84 
Parametrium,  inject  ions  of,  338 
Paranephrin,  135 
Paraphimosis,  328 

Parasacral    anesthesia,    stretching    of    spliincter 
ani  under,  321 
conduction  anesthesia,  320 
Paravertebral  conduction  anesthesia,  279 
in  abdominal  operations,  297 
influence  of,   on  abdominal  sensa- 
tions, 38 
Patella,  sutm-e  of,  381 
Pelvic  nerve,  315,  318,  331 
Pelvis,  conduction  anesthesia  in,  316 
Penis,  amputation  of,  330 
anesthesia  of,  330 
dorsal  nerve  of,  316 
Pericardiotomy,  287 
Pericardium,  operations  on,  287 
Perichondrium,  sensations  of,  33 
Perineal  prostatectomy,  321 
tears,  334 

sutm-e  of,  334 
Perineural  conduction  anesthesia,  157 
injections,  157 

cii-cular  analgesia,  158 
of  connective  tissue,  160 
of  nerve  tracts,  158 
nirvanin  for,  115,  160 
of  periosteum,  158 
of  salt  solution,  160 
subcutaneous,  158 


Periosteum,  cocain  anesthesia  of,  77 
infiltration  of,  153 
localization  of  pain  in,  32 
perineural  injections  of,  158 
Periproctitic  abscesses,  operations  for,  343 
Peritoneum,  anesthesia  of,  298 

sensations  of,  36 
Peroneal  nerve,  deep,  378,  379 

external,  379 
Peronin,  edema  and,  68 

following  injections  of,  68,  127 
Petroleum  ether,  anesthesia  by,  46 

for  freezing,  46 
Pharyngeal  tonsil,  anesthesia  of,  267 
Pharyngotomy,  subhyoid,  277 

suprahyoid,  272 
Pharynx,  sensations  of,  267 
Phenyl  cocain,  97 
Phimosis,  operations  for,  328 
Phlegmon  of  finger,  357 
of  forearm,  369 
of  hand,  362 
urine,  332 
Physiological  solutions,  56 
Plants,  cocainization  of,  80,  81 
Plasmolysis,  56 
Plastic  flaps,  239 

operations  on  face,  239 
Pleura,  puncture  of,  284 

sensation  of,  39 
Plexus,  brachial,  294,  344 
anatomy  of,  351 
anesthesia  of,  349 

indications  for,  365 
Kuhlenkampff' s  technique  of  injec- 
tion, 349 
coccj^geal,  315,  318 
sacral,  315,  329         _ 
Poisoning  from  akoin  injections.  111 
from  alypin,  120 
from  /3-eucain,  106 
of  central  nervous  system  from  anesthesia, 

70,  82,  86,  118 
cocain,  78 

compression  of  vessels  in,  130 
effect  on,  from  coohng  of  tissues,  130, 
133 
of  gelatin  in,  129 
of  oily  solutions  in,  129 
in  larjmgology,  78 
hgation  of  vessels  in,  129 
paralysis  and,  87 
psychical  symptoms  in,  85,  86 
in  serous  cavities,  78 
of  stomach,  79 
ligation  and,  130 
local,  necrosis  from,  65,  66 
from  nirvanin,  115 
from  novocain,  124 

symptoms  of,  124 
from  suprarenin,  143 
from  tropacocain,  102 
symptoms  of,  102 


397 


Popliteal  space,  hygroma  of,  381 
Portio  vaginalis,  sensations  of,  39 
Postoperative'  hernia,  306 

opcnitidiis  for,  30') 
Potasi^inn,  l.n.uu.lc  lM 
Prepatellar  bursa,  3S1 

hygroma,  379 
Prepuce,  anesthesia  of,  328 
Prolapse  of  uterus,  operations  for,  321,  336 
Propajsin,  117 
Prostatectomy,  perineal,  321 

suprapubic,  333 
Prussic  acid,  attempts  at  anesthesia  with,  2 
Psychical  disease  in  cocain  poisoning,  86 

symptoms  in  cocain  poisoning,  85,  86 
Pudic  nerve,  315,  316,  331,  333 
Puncture  of  brain,  195 

of  Gasserian  ganglion,  226 

of  knee-joint,  381 

of  pleura,  284 
Pylorus,  resections  of,  300 
Pyramidal  form  of  injection,  190 


Radial  nerve,  159,  160 

Radius,  fractures  of,  345 

Rectum,  artificial,  carcinoma  of,  343 

extirpation  of,  343 

innervation  of,  34,  315 

operations  on,  340 

sensations  of,  315 
Recurrent  nerve,  275 
Reducible  hernia,  operations  for,  307 
Resection  of  elbow-joint,  368 

of  pylorus,  300 

of  ribs,  284 

of  saphenous  vein,  Trendelenbui'g's,  384 

of  shoulder-joint,  369 

of  skull,  197 

of  upper  jaw,  249 
Resorcin,  cocain  and,  94 
Rhinology,  alypin  in,  120 

cocain  in,  76 
Ribs,  resection  of,  284 

in  emphysema,  284 
in  fixed  dilated  thorax,  287 
Rodent  ulcer  of  cranium,  extirpation  of,  197 


Sacral  anesthesia,  163 
conduction,  163 
plexus,  315,  329 
Salt  contents  of  tissues,  56 

solution,  anesthesia  by,  62 

concentration  of,  absorption  and,  65 
osmosis  by,  59 
perineural  injections  of,  160 
Saphenous  nerve,  378,  379 

vein,  resection  of,  Trendelenburg's,  384 
Saponin,  25 
Sarcoma  of  skull,  201 


Scalp,  operations  on,  104 

Schleich's  cocain  solutions,  freezing  point  of,  151 

wheal,  67 
Schlosser's  injections  into  foramen  ovale,  tech- 
nique of,  226 
Sciatic  nerve,  118,  161,  374 
dislocation  of,  346 
Sciatica,    warning    against   use    of    stovain    in, 

118 
Scopolamin,  morphin,  171 
Scrotum,  operations  on,  325,  333 
Sensation,  27 

effect  of  anikosmotic  solutions  on,  58 
of  organs,  31 
testing  of,  67 
Serous   cavities,  absorption  of  watery  solutions 
from,  65 
cocain  poisoning  in,  78 
sensation  of,  36 
superficial  anesthesia  of,  147 
membranes,  anesthesia  of,  146 
Sexual  organs,  innervation  of,  315 

sensation  of,  266 
Shoulder,  anesthesia  of,  369 

lipoma  of,  369 
Shoulder-joint,  disarticulation  of,  369 
operations  on,  369 
resection  of,  369 
Sinuses,  accessory,  innervation  of,  240 

frontal,  operations  on,  244 
Skin,  injections  into,  endermatic,  199 
subcutaneous,  157 
sensations  in,  30 
transplantation  of,  369,  373,  384 
Skull,  fracture  of,  196 

imiervation  of  roof  of,  194 
operations  on,  194,  197 
resection  of,  197 
sarcoma  of,  201 

temporal  region  of,  resection  of,  201 
Smell,  paralysis  of  sense  of,  from  cocain,  84 
Solutions,    concentration    of,    anesthetic    action 
and,  68 
duration  of,  72 
Spermatic  nerve,  306 
Sphincter  ani,    stretching  of,    under   parasacral 

anesthesia,  321 
Spinal  anesthesia,  loss  of  abdominal  sensations 

in,  40 
Spinal  column,  operations  on,  278 

nerve,  204 
Spleen,  sensations  of,  36 
Stenocarpin,  126 

Sterilization  of  cocain  solutions,  97 
of  iustniniciits,  176 

t,Tlnii(|ii<'(.r,  176 
of  nuvocaiii,  ITS 
of  suprarcnin  tnhlcts,   ITS,  179 
Sternum,  opcratidiis  dii,  I'SS  _ 
Stomach,  cdcaiii  poisdiiiiiK  <>f,  79 

sensations  of,  34 
Stovain,  70,  117 

injections,  gangrc'iie  from,  117 
suprarenin  and,  140 


Strangulated  hernia,  operations  for,  310 
Stretching    of    sphincter    ani    under    parasacral 

anesthesia,  321 
Strophanthin,  127 
Stypage  according  to  Bailey,  50 
Subconjunctival  injections,  232 
Subcutaneous  connective  tissue,  anesthesia  of,  82 
Subcutin,  suprarenin  and,  117,  140 
Subhyoid  pharyngotomy,  277 
Subphrenic  abscesses,  288,  291 
Superficial  cervical  nerve,  194,  267 
Superior  alveolar  nerve,  213,  2-56,  258 
Supraclavicular  nerve,  267,  279,  292 
Supracondylar  fractures  of  humerus,  345 

osteotomy  of  femur,  382 
Suprahyoid  phar3Tigotomy,  272 
Supra-orbital  nerve,  161 
Suprapubic  prostatectomy,  333 
Suprarenin,  133 

absorption  of,  66,  142 

action  of,  with  novocain,  123,  135,  175 

akoin  with,  140 

alypin  with,  141 

anemia  with,  147 

dosage  of,  in  drops,  131,  179 

effect  of,  on  local  and   general   poisoning, 
144 

gangrene  from,  145 

holocain  and,  141 

importance  of,  to  local  anesthesia,  138 

in  laryngology,  137,  139,  142,  143 

precautions  in  operations  on  palate,  261 
to  prevent  injury  to  vitality  of  tissues, 
145 

sterilization  of,  176 

stovain  and,  140 

subcutin  and,  117,  140 

synthetic  preparations  of,  136 

tablets,  sterilization  of,  178,  179 

tropacocain  and,  139 
Suture  of  patella,  381 

of  perineal  tears,  334 
Sympathetic  nerve,  28,  278,  280 
Synovial  membranes,  anesthesia  of,  146 

sensations  of,  33 
Synthetic  preparation  of  suprarenin,  136 
Syringe  for  local  anesthesia,  171 


Tablets  in  local  anesthesia,  178 
Taste,  paralysis  of  sense  of,  by  cocain,  84 
Teai'-sac,  operations  on,  235 
Teeth,  extraction  of,  after  cooling,  46 
innervation  of,  215,  256 
lower,  operations  on,  259 
upper,  operations  on,  257 
Temperature,   effect   of,   on   anesthesia  injected 
into  tissue,  54 
sense,  cocain  and,  83 
in  cooled  tissues,  47 
nerve  compression  and,  43 


Temporal  region  of  skull,  resection  of,  201 

Tendo  AchiUis,  tenotomy  of,  377 

Tendon  tissues,  31 

Tenotomy  of  tendo  Achillis,  377 

Terminal  anesthesia,  40,  76 

Testicle,  sensations  of,  39 

Testis  ablatio,  328 

Thermo-isolator  for  methyl  chloride,  50 

Thiersch  grafts,  369,  373,  384 

Thigh,  anesthesia  of,  370 

fold  of,  anesthesia  of,  307 

innervation  of,  307 

tumors  of,  384 
Thoracic  nerve,  278 
Thoracoplasty,  287,  288 
Thoracotomy  for  empyema,  285 
Thorax,  emphysema  of,  287 

innervation  of,  287 

operations  on,  278 
Thyroid  artery,  inferior,  ligation  of,  271 
superior,  ligation  of,  271 

gland,  sensations  of,  39 
Thyroidectomy,  272,  273 
Tibia,  dislocation  of,  346 

fractures  of,  345 
Tibial  nerve,  378,  379 
Tissues,  salt  contents  of,  56 
Toes,  anesthesia  of,  376 

big,  disarticulation  of,  376 

circular  analgesia  of,  158 
Tongue,  anesthesia  of,  262,  263 

carcinoma  of,  radical  operation  for,  265 

innervation  of,  262 

operations  on,  262,  263 

sensations  of,  262 
Tonogen,  135 
Tonsils,  operations  on,  262 

pharyngeal,  anesthesia  of,  267 
Tonsillar  region,  anesthesia  of,  264 

sensations  of,  262 
Tonsillectomy,  262,  264 

anesthesia  for,  264 
Touch,  isolated  cessation  of,  after  Hgation,  43 
Toxic  action  in  arterial  anesthesia,  167 

in  venous  anesthesia,  167 
Trachea,  sensation  of  mucosa  of,  34 
Tracheotomy,  274 

Transplantation  of  skin,  369,  373,  384 
Trendelenburg's  resection  of  saphenous  vein,  384 
Trigeminal  nerve,  194,  210 
anesthesia  of,  210 
Trigonum  retromolare,  221 
Tropacocain,  concentration  of,  101 

in  dentistry,  103 

dosage  of,  102 

edema  and,  102 

after  injection  of,  68,  101 

freezing  point  of,  101 

physiological  action  of,  100 

poisoning  from,  102 
symptoms  of,  102 

suprarenin  and,  139 
Tumefaction  anesthesia,  60 


399 


Tumefaction  necrosis,  60 

pain,  59 
Tumors  of  l^roast.  bonisn,  294 
iii,ilimi;int,  L",)4 

of  in-imml  n-Kui,  384 

of  thigh,  ;:;s4 

Tympanic  cavity,  anesthesia  of,  206 
opening  of,  216 


Ulcer,  rodent,  extirpation  of,  197 
Ulnar  nerve,  158,  160,  363 
Umbilical  hernia,  305 

operations  for,  305 
Upper  extremities,  innervation  of,  348 
Urethra,  operations  on,  330-332 

sensations  of,  34 
Urethral  fistula^,  operations  for,  330 
Urethrotomy,  330-332 
Urine  phlegmon,  332 
Uteri,  ganglion  cervicale,  315 
Uterus,  extirpation  of,  334,  338,  339 

operations  on,  338,  339 

prolapse  of,  operations  for,  321,  336 

sensations  of,  35 


Vagina,  extirpation  of,  333 
operations  on,  333,  353 


Vagina,  sensations  of,  25 

Vagus  nerve,  194,  204,  262,  267 

Vein  anesthesia,  73,  1()3 

ill  (iiMTMtinns  on  leg,  379 

in  resect  idii  of  knee-joint,  382 

Vulva  operations,  sensation  of,  35 


W 

Water,  physiological  acition  of  injections  of,  60, 
61,  62 
subcutaneous   injection   of,    anesthesia   fol- 
lowing, 64 
Wheal  formation,  according  to  Schleich,  183 

for  testing  anesthesia,  points  of  entrance 
for  needle,  183 
Schleich's,  67 
Wheals  in  series  according  to  Schleich,  59,  67 
Wounds,  anesthesia  of,  146 


YoHiMBiN  as  an  anesthetic,  127 


Zygomatic  nerve,  232 
Zykloform,  117,  147 


13   21  98 


5EP  li  1972 


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